Wells was one of nearly 400,000 Kentuckians enrolled in Medicaid who lost their dental benefits after Gov. Matt Bevin made cuts.
Michael Clevenger/Courier Journal
For Krista Seymour, Medicaid is essential for her to obtain the treatment that keeps her thyroid cancer in check.
“If I can’t afford my medication, I will die,” she said.
But Seymour fears she will lose benefits under pending changes to the state’s Medicaid program that require some people to work or volunteer 80 hours a month to keep health coverage.
A freelance television producer, Seymour, of Louisville, said her hours fluctuate depending on her health and job assignments.
People deemed “medically fragile” are supposed to be exempt from the new rules the state plans to launch April 1 as part of a plan by Gov. Matt Bevin to overhaul the state’s Medicaid program. They would not have to meet the work obligation, pay premiums and meet other requirements.
But Seymour and others said they have found it difficult, if not impossible, to find out exactly what “medically fragile” means, a designation that also could affect coverage for people with mental illness, the homeless and victims of domestic violence, they said.
“I keep getting denied,” Seymour said.
Doug Hogan, a spokesman for the Cabinet for Health and Family Services, said the state has provided guidelines for health providers to use in compiling information about whether someone should be considered medically fragile and provided a link to a 10-page list of conditions that could qualify someone.
And he criticized those he said are contributing to the confusion.
“We are concerned that rather than disseminate good information out into the public and work on ways to improve the program, some advocates create more angst and confusion among the public — doing a disservice to those they purport to serve,” he said.
The governor’s changes are aimed largely at the “able-bodied” adults among the about 500,000 people added to Medicaid under the Affordable Care Act, which now covers nearly 1.4 million Kentuckians.
Advocates on a press call this week that included Seymour said the failure to get consistent answers from the state about who is determined medically fragile is among their chief concerns about the plan.
“Medicaid is not giving us a clear answer,” said Sheila Schuster, director of the Kentucky Advocacy Action Network, a coalition of health advocates. “It’s a mess right now.”
Andrea Miller, with the Kentucky Coalition Against Domestic Violence, said her organization is grateful that victims of such abuse can seek exemption as “medically fragile” but worried they won’t be able to obtain it under what advocates said are the state’s complicated and confusing procedures.
“Victims have lost coverage before through no fault of their own,” she said. “Our concern is about victims who may fall through the cracks.”
Those supposed to be designated medically fragile also include people with severe mental illness, advocates on this week’s call said.
But Ramona Johnson, president of Bridgehaven Mental Health Services in Louisville, said many of their clients have been rejected as medically fragile while others have been accepted — even though they all have similar diagnoses of serious mental illness.
“We have many more people that should qualify,” she said.
People seeking such status must apply through their managed care providers. Five such companies, known as Managed Care Organizations, handle Medicaid coverage for most Kentuckians covered by Medicaid.
Those who are rejected may appeal, Hogan said.
Seymour said she’s gone in circles with state Medicaid officials and her MCO over how to obtain a “medically fragile” designation and why she doesn’t qualify.
“I call the state and the state throws it back to the MCO,” she said. “They say I’m not sick enough.”
Johnson said Bridgehaven, which promotes work and recovery, submitted applications known as “attestations” to MCOs on behalf of 44 clients for “medically fragile” status. Of those, 28 were denied although all clients had similar circumstances, she said.
“There is no explanation given or no apparent reason for the denial,” she said.
Johnson said her nonprofit agency works to help its clients get jobs, but many will not be able to meet the 80-hour-a-month requirement because of their illness.
Another population that could be affected is the chronically homeless. The state has said such individuals could be exempt from the work requirements, monthly premiums and other rules if they are determined to be medically fragile.
But advocates said it may be difficult to collect and submit information on behalf of homeless people, often with mental health or drug and alcohol addiction. They also are concerned that some people suffering from addiction may not qualify because of the complex system of determining eligibility.
Meanwhile, advocates on this week’s call noted that the Medicaid population has dropped this year, causing some to question the need for changes Bevin has said are necessary to slow the growth of the program he has said is not sustainable.
Dustin Pugel, with the Kentucky Center for Economic Policy, said his calculations, based on state data, show enrollment has declined by about 97,000 people in recent months, a decline he attributes largely to the improving economy and the state’s low unemployment.
It also amounts to a savings of about $700 million in the Medicaid program at a time when officials are warning of possible shortfall of around $300 million by the end of the fiscal year, Pugel said.
State officials claim a smaller decline, citing a decrease of about 54,500 people over the same period.
Pugel said he didn’t include children covered through the Kentucky Children’s Health Insurance Program, a separate Medicaid plan for children of low-income working adults, which has grown in enrollment. And he used a different point in time for collecting the data, he said.
But either calculation shows a significant decline in the program after years of rapid growth in Medicaid enrollment, he said.
Meanwhile, with the federal government paying about 80 percent of the state’s $11 billion in Medicaid costs, the program has been successful in increasing access to health care for Kentuckians, Pugel said.
“Medicaid has been an enormous success for Kentucky, not just for our health but for our economy,” he said.
Hogan said the changes are not meant to save money, though state officials project a savings of $2.4 billion — $300 million of that in state money — over the five-year life of the plan.
Rather, he said, it is to “improve health outcomes and make the program sustainable.”
But advocates on this week’s call said they fear worse outcomes for those who depend on Medicaid.
“That’s what scares me the most,” Seymour said. “They’re going to sink or swim.”
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