Idaho has submitted its waiver request to let some people who would be covered by Medicaid expansion stay on private insurance.
The “Section 1332 Coverage Choice Waiver” was submitted Monday and, if approved by the Centers for Medicare and Medicaid Services, would give people making between 100 and 138 percent of the poverty level the option of getting federal tax credits to buy insurance on the Your Health Idaho state exchange instead of going on Medicaid when expansion kicks in on Jan. 1, 2020. An estimated 18,000 Idahoans who have exchange insurance now will qualify for expanded Medicaid coverage and would, without a waiver, have to give up their current policies for Medicaid.
The state has already taken public comment on the proposed waiver, and also took some public comment on a “Section 1115” Medicaid waiver request that is related to the proposal to let some people stay on the exchange. However, CMS had some additional questions on that waiver request, said Department of Health and Welfare spokeswoman Niki Forbing-Orr, and it isn’t clear if the state needs to submit two waiver requests or just the 1132 waiver. Forbing-Orr said the state is in talks with CMS to see what is required.
“Recent discussions with CMS late last week suggested necessary changes to the dual-track 1115 Coverage Choice waiver, and the possibility that an 1115 waiver may not be necessary in addition to the 1332 waiver,” DHW posted on its website. “Based on this feedback, IDHW has ended the public comment period for the Section 1115 Coverage Choice waiver application, which began on July 3, while seeking further guidance from CMS and the Center for Consumer Information and Insurance Oversight. The department will initiate a new comment period if needed.”
The Affordable Care Act originally would have used the threat of withholding Medicaid funding to compel every state to expand Medicaid, but a 2012 U.S. Supreme Court ruling made it a state option. Lawmakers in many Republican-run states, including Idaho, didn’t expand Medicaid. Idaho voters approved Medicaid expansion via ballot initiative in November 2018. Lawmakers approved funding for expansion during the 2019 session but also passed a bill to request federal waivers to make some changes to the program, including work requirements, letting the state spend some Medicaid money on mental health and substance abuse treatment and putting restrictions on using outside family planning providers.
The state has yet to submit waiver requests for those other changes. Forbing-Orr said those waivers are less urgent since they won’t immediately impact the number of people covered by expansion and it would be less disruptive if those changes are implemented after expansion coverage kicks in.
“Because those don’t really affect enrollment so much, we have been prioritizing the coverage choice waivers, because those really affect enrollment which begins on Jan. 1, 2020,” she said.
It remains to be seen which waiver requests CMS will approve.
“I think some of them have a chance,” Gov. Brad Little said Wednesday.
Little, who was in Idaho Falls to tour the new burn center at Eastern Idaho Regional Medical Center, said getting the coverage choice waiver approved could be a “heavy lift,” since CMS would only approve a waiver if it is cost-neutral to the federal government. CMS approved a waiver earlier this year to let Utah expand Medicaid while letting people making between 100 and 138 percent of the poverty level stay on the exchange, but at a lower federal matching funds rate than the 90 percent federal/10 percent state ratio for full Medicaid expansion.
“The budget neutrality really is what CMS will look at,” Little said.
Reclaim Idaho, the group that spearheaded last year’s Medicaid expansion push and lobbied against putting any restrictions on it during the 2019 legislative session, has come out against the proposal to insure some people on the exchange, saying it could cost Idaho taxpayers more than straight expansion.
“Medicaid expansion benefits are far more reliable, more comprehensive, and much safer for Idaho families,” Reclaim Idaho Executive Director Rebecca Schroeder said in a news release in late June. “Legislators are putting thousands of Idahoans in jeopardy with this restriction. What they are proposing is not just irresponsible, it’s cruel.”
Idaho’s request to spend some Medicaid money on mental health treatment is similar to a waiver that has been allowed in many other states and is expected to be approved. Work requirements, which were the most controversial of the proposed waivers, have been approved in numerous states and the Trump administration supports the idea. The final fate of the concept could be decided by the courts though — opponents have sued to block work requirements elsewhere, and in March a federal judge sided with them and blocked them in Kentucky and Arkansas.
Little’s tour of EIRMC was mostly about the new burn center, which opened April 1 and is the only burn center in Idaho, Wyoming, Montana and North Dakota, letting eastern Idahoans get burn treatment closer to home.
“Trying to keep those patients here in our state is best,” said EIRMC Chief Operating Officer Jeff Sollis. “It’s a lot cheaper to stay here. More accessible than Salt Lake and Seattle.”
However, Medicaid expansion did come up briefly as Little chatted with Sollis. Idaho’s hospitals and medical lobbying groups were among the major supporters of the expansion initiative. Sollis thanked Little for backing expansion and said it would bring federal money to the state.