Some consumer advocates expressed concern Wednesday that some people with mental illness and certain medical conditions, such as cancer, face trouble navigating through and meeting the requirements of the state’s newly approved Medicaid overhaul known as Kentucky HEALTH.
A group, which included some policy analysts, a service provider, a patient and others, took part in a conference call by Kentucky Voices for Health. The group leads the InsureKY Campaign, which promotes policies to improve coverage, and has been a vocal opponent of Kentucky HEALTH.
The U.S. Centers for Medicare & Medicaid Services approved the plan, also known as a Section 1115 waiver, last month, following a judge’s ruling that the Trump administration’s original approval was arbitrary and capricious. The program is expected to start next April, with an 80-hour-a-month work requirement being phased in across the state on a regional basis.
“You will hear the state comment all the time that work is necessary for people to be healthy, and that’s really got it backwards,” said Sheila Schuster, executive director of the Advocacy Action Network in Kentucky, who was on the call. “If you ask employers, they will say they need a healthy and educated workforce, so it makes no sense to us to put these barriers in front of people to prevent them from getting health coverage when we need them to be healthy first.”
The Bevin administration has promoted Kentucky HEALTH as a way to improve health, persuade people to get preventive care and graduate to private coverage. But critics have asserted that the plan jeopardizes the health care of tens of thousands and is an excuse to kick people off the Medicaid rolls by making them jump through hoops, such as paying premiums or having to report hours worked, or face being locked out.
Previously, the state has noted that the work requirement has some flexibility built in, such as being able to meet it with other forms of acceptable “community engagement,” such as volunteering or job training.
Although some people will be able to get an exemption for various reasons, such as being determined to be medically frail, Ramona Johnson, the president and chief executive of Bridgehaven Mental Health Services, said the results have not been uniform, so far.
“We’ve been advised on more than one occasion that anyone who is diagnosed with a severe and persistent mental illness will automatically be considered medically frail and therefore exempt from the work or community engagement requirements, but we really have not found this to be true with any consistency, and we’ve been submitting information on our members for several months,” Johnson said. “The managed care organizations that we work with are receiving denials of medically frail status on some of our members, all of whom have a severe and persistent mental illness.”
In a statement Wednesday, the Kentucky Cabinet for Health and Family Services said the state doesn’t determine whether an individual is designated medically frail. Instead, an automated tool makes the determination based on claims data, or a provider can attest to a person’s medical or mental health condition if there isn’t enough claims data, the state said.
“Medicaid sets the state policy, and the MCOs (managed care organizations) administer according to policy so that practices are consistent across the state,” the Cabinet noted.
A provider can contact the Medicaid beneficiary’s managed care organization, such as Passport Health Plan, “to inquire about status and whether any more information is needed for approval,” according to the Cabinet. “There is also an appeals process for those who believe they were inappropriately denied” a medically frail designation.
The state also referred to certain people being able to declare or “self-attest” to being medically frail because they are part of a special group, such as the chronically homeless or domestic violence survivors.
However, in a subsequent email, after Insider asked whether people would have to reapply for medically frail status that was previously granted, the state said, “We are working with CMS on how the previous medically frail status can be applied. There is no ‘official’ status until the program begins.”
Johnson said Bridgehaven supports work as an essential component of recovery from mental illness and even helps people to find jobs but requiring them to work a certain number of hours isn’t always realistic. “For those of our members who can and do work, the 20 hours a week or the 80 hours a month expectation is really very arbitrary,” she said. “… It’s not based on the person’s capacity to work and maintain their mental health stability,” and some “may work 20 to 25 (hours) one week and then the next week be unable to work more than 10 or 12 because of the stress of the previous week’s workload.”
Thyroid cancer patient Krista Seymour, a freelancer in television sports production, said she also works an inconsistent number of hours and is sometimes unable to work because of her illness and the ramifications of treatment. She said she has been denied medically frail status multiple times but hasn’t been able to find out the specific criteria that she needs to meet to get the designation.
“I’m out here trying to find out as much as I can,” Seymour said. “I’m out here trying to figure out how to jump through the hoops so that I can keep my coverage and continue working, but I’m also worried that should I fall off the Medicaid rolls and be put into the marketplace, I’ll not be able to find a plan I can afford.”
The newly approved waiver is nearly identical to the one approved in January, with the same barriers and red tape, said Emily Beauregard, executive director of Kentucky Voices for Health.
Without the work requirement being in place, nearly 97,000 people came off Medicaid between January and September, mainly because their income exceeded the limit or they failed to provide information in a timely manner, said Dustin Pugel, a policy analyst with the Kentucky Center for Economic Policy. He estimated that equates to Medicaid savings of nearly $700 million in combined federal and state dollars and says he is skeptical about a government projection of a significant budgetary shortfall.
With an improved economy, he added, “I’m not surprised that the rolls are dropping.”