State officials on Tuesday submitted their application to President Joe Biden's administration for a waiver to retool Arkansas' version of Medicaid expansion.
The program provides health care coverage to more than 300,000 low-income Arkansans.
The Medicaid expansion program provides private health insurance coverage for adults aged between 19 and 64 who earn up to 138% of the federal poverty level, which is $17,774 for a single person and $36,570 for a family of four.
Its enrollment totaled 321,053 on June 1, according to the latest figures on the state Department of Human Services' website. On March 1, 2020, prior to the covid-19 pandemic arriving in Arkansas, the program's enrollment totaled 250,233.
In this year's regular legislative session, the Republican-dominated General Assembly and GOP Gov. Asa Hutchinson enacted a bill aimed at overhauling the state's Medicaid expansion that is now called Arkansas Works into the proposed Arkansas Health and Opportunity for Me program, or ARHOME, under Act 530. The state proposes to operate the program for five more years, starting Jan, 1, 2022, through Dec. 31, 2026.
The federal government would continue to pay 90% of the cost of the program and the state would pay the other 10%.
The application was submitted to the U.S. Centers for Medicare and Medicaid Services after a month-long public comment period.
"We're expecting an answer this fall," said state Department of Human Services spokeswoman Amy Webb.
The state's Medicaid expansion program was initially authorized by the 2013 General Assembly and then-Gov. Mike Beebe, a Democrat, as the private option with a sunset of Dec. 31, 2016. The private option was replaced by the current version, which was authorized under the Arkansas Works Act of 2016 and expires Dec. 31, 2021.
States have the option of authorizing Medicaid expansion programs under the federal Patient Protection and Affordable Care Act signed by then-President Barack Obama. The federal law is often called Obamacare. Arkansas has obtained waivers under the federal law for its versions of Medicaid expansion.
The work requirement for Arkansas Works hasn't been enforced since a federal judge ruled in March 2019 that federal law didn't allow then-President Donald Trump's administration to authorize that requirement in Arkansas.
The state's proposed ARHOME program doesn't include a similar work requirement. But the application for the waiver states, "If federal law or regulations permit the use of a work and community engagement requirement as a condition of eligibility in the future, the State will seek to amend the Demonstration."
According to the application, ARHOME's three overarching goals include:
• Improving health outcomes among Arkansans, particularly in maternal and infant health, rural health, behavioral health and for those with chronic diseases.
• Providing incentives and support to help individuals, particularly young adults in target populations, and help them move out of poverty.
• Slowing the rate of growth in federal and state spending on the program so the program will be financially sustainable.
Under ARHOME, the state Department of Human Services plans to implement an inactive status, starting in 2023, for people in the program who don't do things such as attend school, work, select a health insurance plan or use their health insurance in any way. Those people will be moved to fee-for-service Medicaid until they become active, according to department officials.
"We still don't know when the federal [coronavirus] public health emergency will end, so even if it does end at the end of this calendar year, you spend several months before you have redetermined your whole population," Department of Human Services Secretary Cindy Gillespie said last month. "There is going to be a great deal of volatility in the population in 2022 because of the [possible] ending of the public health emergency, so that's why we are waiting until 2023."
SUPPORT FOR ARHOME
Bo Ryall, president and chief executive officer for the Arkansas Hospital Association, said in a letter dated July 12 to Gillespie that the association "applauds the outstanding efforts of Governor Asa Hutchinson, your leadership team at the Department of Human Services, the 93rd General Assembly of the Arkansas Legislature, and the long list of stakeholders who worked collaboratively to ensure that Arkansans under 138 percent of the federal poverty level remain eligible to access Arkansas' health care system."
The hospital association, which represents more than 100 health care facilities and their more than 50,000 employees, "enthusiastically supports" ARHOME's proposal for the continuation of qualified health plan coverage for Arkansas' expanded adult population under the premium assistance model, he said.
However, "We are concerned that the proposed cost-sharing increases could cause individuals to drop Medicaid coverage and we disagree with the premise that premiums are necessary to 'assess whether individuals value coverage as insurance,' " Ryall wrote in his letter to Gillespie.
Medicaid's primary purpose is to provide access to health care services for low-income individuals, he said, and it's unlikely that reductions in participation because of increased cost-sharing reflect individuals devaluing coverage rather than the necessity of making painful economic choices among competing priorities, he said.
"The AHA does appreciate that there is no proposed cost sharing for inpatient hospital stays, which could have caused adverse effects such as avoidance of addressing serious medical issues."
Sen. Missy Irvin, R-Mountain View, who sponsored the bill that became Act 530 of 2021, said in a written statement to the Arkansas Democrat-Gazette that many of the components of the proposed ARHOME program have been in place in other states and approved by the federal government or have been options available for the state to use, such as cost-sharing and co-pays.
"There must be personal accountability for utilizing this benefit in a way that promotes and drives better health outcomes," she said. "This was very important to our current Legislature. For example, if the beneficiary is using the emergency room as a clinic, because they don't want to make an appointment, or haven't established a patient relationship, or other reasons, then there should be a higher co-pay to discourage the inappropriate use of the ER.
"With any government program, I believe there should be the goal of moving someone from a state of dependency to a state of independence."
Under ARHOME, premiums would continue for individuals with income of more than 100% of the federal poverty level, but the amounts will increase from $13 a month for all individuals with income above 100% of the federal poverty level to $22.44 a month for individuals between 101% and 120% of the federal poverty line and to $26.88 a month for individuals between 121% and 138% of the federal poverty level, Webb said.
In the current Arkansas Works program, only individuals who make above 100% of the federal poverty level are subject to co-pays charged by providers, she said. In the current program, individuals subject to copays do not pay more than $60 per quarter.
Under ARHOME, individuals between 21% and 138% of the federal poverty level would be subject to copays, she said.
Under this program, the copayments will be capped at the following quarterly amounts based on an individual's income:
• 21-40% of the federal poverty level with a cap of $20.96
• 41-60% of the federal poverty level with a cap of $40.92
• 61-80% of the federal poverty level with a cap of $60.89
• 81-100% of the federal poverty level with a cap of $80.85
• 101-120% of the federal poverty level with a cap of $95.29
• 121-138% of the federal poverty level with a cap of $114.15
"There is also an overall cap of 3% of household income on copayments to be applied quarterly so that the combination of premiums and copayments for people above 100% [of the federal poverty level] will not exceed the federal cap of 5%," Webb said. "This will ensure enrollees will have the same actuarial value. The cap provides greater protection to low-income Arkansans compared to individuals in other states who have no cost sharing protections."