Your Questions, Answered:

The Affordable Care Act and CYSHCN

Many of you who responded to our Communications Survey asked for more information on Health Care Reform and its implications for children and youth with special health care needs (CYSHCN). In each monthly issue of Catalyst Center Coverage, we'll tackle a question we've been asked about the Affordable Care Act (ACA) and its impact on CYSHCN. If YOU have a question, please contact Emily Winter, Catalyst Center Research Assistant and editor of Catalyst Center Coverage, at ewinter@bu.edu. While we can't guarantee we can answer every question, we'll try to get to as many as we can.

Q: What is a grandfathered plan?  

A: "Grandfathering" health plans is the result of a compromise that was made as
the ACA was being developed to reassure those who did not want the health care coverage they had to change.  Plans in the individual and group markets that were in effect on March 23, 2010, the day the ACA was signed into law, are called grandfathered plans and they are "frozen in time" or exempt from many, but not all, of the provisions in the ACA as long as they keep their grandfathered status.  A plan can lose its grandfathered status by making major changes, such as raising premiums or reducing benefits significantly.  As health care costs continue to rise, plans will have to do one or both of these to maintain their business model.  So over time, plans will gradually lose their grandfathered status until there aren't any left. 

 In the several years this is expected to take, grandfathering has important implications for CYSHCN.  It is estimated that approximately 80% of people with employer-sponsored insurance will be in grandfathered plans in 2011.[1]  Because the majority of CYSHCN currently have private coverage, many ACA provisions will not apply to them as long as they or their families are enrolled in grandfathered plans.[2]  An awareness of which provisions have grandfathering exemptions associated with them will be important to analyzing the impact of the ACA on CYSHCN over time, monitoring compliance with the law, advocating effectively for improvements to it and providing accurate benefits counseling to families. One resource with additional information on this topic can be found in our side-by-side comparison of major provisions of the ACA affecting CYSHCN.    

What are the Maintenance of Effort (MOE) Provisions? 

The Maintenance of Effort (MOE) provisions under both the American Recovery and Reinvestment Act (ARRA) and the Affordable Care Act (ACA) require states to keep the eligibility criteria for their Medicaid and Children's Health Insurance Program (CHIP) that they had in place on March 23, 2010, the day the ACA was signed into law[i].  Under MOE, states cannot make it more difficult to enroll in or renew Medicaid or CHIP coverage.  The MOE provisions under the ACA are in place for adults until 2014, when the state exchanges are scheduled to go into operation and income eligibility for Medicaid expands to 133 percent of the Federal Poverty Level (FPL).  For children in Medicaid and CHIP, the MOE provisions are in effect for much longer; until September 30, 2019.  States who violate the MOE provisions risk losing their federal funding match.

What's the Deal with MOE?

States Want To Cut Medicaid Spending. Are CYSHCN At Risk? 

This month, we received a series of questions on MOE that we thought would be helpful to include in this month's Catalyst Center Coverage. However, we went into some detail in our response, making it a bit too lengthy for the "Your Questions, Answered" section. Instead, we've included it below.

Q: I've been hearing a lot about how states are pressuring the federal government to get rid of the maintenance of effort (MOE) provisions in health care reform.  I'm worried that children with special health care needs might be at risk for losing their Medicaid coverage if that happens.  What do I need to know about this issue?

A: It's a cruel fact that in times of high unemployment such as we are experiencing now, more people become eligible for coverage through Medicaid because of a loss of income. At the same time states are less able to afford higher numbers of enrollees because they are collecting fewer taxes and fees that help fund their share of the program.  Most states (at least 45[i]) and the District of Columbia are facing serious budget deficits in FY12, and difficult cuts in state spending are being considered just about all over.  Every past issue of our own Week in Review has highlighted state budget issues in some way, but the place where tension appears to be among the highest is in Medicaid.  Why is Medicaid such a popular focal point for reducing state spending, especially if citizens who have lost not only their jobs but their access to employer-sponsored health insurance need it more than ever?  It's often cited as the single biggest line item in any state's budget, so that understandably draws attention to it[ii].  However, Medicaid isn't the "budget buster" it may appear to be.  Funding for Medicaid is a federal-state collaboration.  Once the federal government's contribution (also known as the "federal match") is factored in, Medicaid is no longer the largest single slice of the state budget pie[iii].   However, it's still a substantial amount.  As the enhanced Medicaid funding states have been receiving from the federal government under the American Recovery and Reinvestment Act (ARRA) comes to an end June 30^th and the effects of the Great Recession continue, states are looking for savings everywhere they can.

Q: How do states want to cut back on Medicaid?

A: There are several strategies for reducing Medicaid spending that have worked for states during tough times in the past.  One is cutting back on eligibility for Medicaid.  The federal government requires that states cover certain populations (known as mandatory eligibility groups) in order to receive their federal funding match.  States have flexibility in covering other populations if they choose to; these are called optional eligibility groups.  (See the sidebar for more information on mandatory and optional groups.)  Many states want to drop optional groups from eligibility to reduce the number of enrollees, which in turn will reduce the state's Medicaid spending.   The number of Medicaid and CHIP enrollees in optional populations is not insignificant.  The Georgetown Center for Children and Families issued a report last week which estimated that approximately 35 percent of Medicaid and CHIP beneficiaries (including 14.1 million children) are members of optional groups and so would be at risk for losing their health care coverage if states were allowed to drop them.  Children with special health care needs (CSHCN) who qualify for Medicaid through the Supplemental Security Income (SSI) program are safe, but those who qualify through waivers, buy-in programs, medically needy programs and other optional, disability-related pathways could be at risk, as would all children who are currently covered above the mandatory income limit for their age group.  Recently, the Catalyst Center reviewed the Medicaid Statistical Information System (MSIS) State Summary Datamart[iv] for the number of children under age 20 in medically needy programs and Home and Community-based Service (HCBS) waivers. The total was over 900,000 and didn't include all disability-related categories of eligibility or children currently enrolled above the mandatory income limits.

Q: Where do the maintenance of effort (MOE) provisions come in?

A: ...Read the rest of this Q & A on our website. 

Medicaid Mandatory and Optional Eligibility Populations

 Sidebar to "What's the Deal with MOE?"

What groups must states cover in their Medicaid programs?  What groups can they choose to cover?  

Medicaid eligibility is complicated because it includes both categorical and financial eligibility criteria.  It differs from state to state because there is also some flexibility around including optional groups and somewhat higher incomes.The foundation of Medicaid eligibility is the mandatory groups, which include several broad categories:

• Children under age 1 whose family income is at or below 133% of the FPL;
• Children ages 1-5 whose family income is at or below 100% of the FPL;
• Pregnant women whose family income is at or below 133% of the FPL;
• Adults in very low income families with dependent children;
• Children and adults with disabilities who receive Supplemental Security Income (SSI);[i] 
• Recipients of adoption assistance and children in foster care under Title IV-E of the Social Security Act;
• Persons with low income who are blind; and,
• Some low income seniors.

States that do not cover mandatory eligibility groups run the risk of losing their federal funding match.  For a more comprehensive description of mandatory eligibility groups, visit the Centers for Medicare and Medicaid Services (CMS) website. 

For a comprehensive description of optional eligibility groups, visit this page on the CMS website.

EVENT:

24th Annual Children's Mental Health  

Research and Policy Conference

The "Tampa Conference" 

March 20 - 23, 2011

Tampa, Florida

Register here for the Tampa Conference.  

Attend workshops and plenary sessions, view poster presentations, pick up the latest materials on children's mental health topics, and network with policymakers and researchers at this 3-day conference.

From the conference's website: "The 24th Annual Children's Mental Health Research and Policy Conference draws from an international audience of leading researchers, policy-makers and family advocates who are focused on efforts to improve the opportunity for children and families to realize their potential in the communities in which they live." 

Recent Media Highlights 

Defining 'Essential' Care: Regulators Move to Specify Coverage Under Health Law; Insurers Seek Flexibility 

By:  Avery Johnson

Wall Street Journal

February 28, 2011

The federal health care reform law requires plans offered through the state Exchanges in 2014 to include so-called "essential benefits". The law includes 10 broad categories of care but left defining the specifics to federal regulators. This week, the Institute of Medicine (IOM) will convene the second in a series of meetings intended to help the Department of Health and Human Services determine what and how much of any particular service will be part of the essential benefits. The challenge will be to strike a balance between an expansive and specific list of benefits that can help address underinsurance for CYSHCN and premiums that are affordable.  

More information on the IOM's essential benefits work. 

HHS to Governors: You have flexibility on health reform implementation 

By: Mary Agnes Carey

Kaiser Health News

February 25, 2011

HHS Secretary Kathleen Sebelius responded in a letter on Feb. 24th to governors who are urging more flexibility for states in implementing health insurance Exchanges. Sebelius says in the letter that the Affordable Care Act gives states authority to pick insurers to allow for a diversity of health plans. HHS has also offered or already provided $2.8 billion to help states implement the law.  

Read the HHS letter. 

Medicaid/CHIP update 2011

January 2011

New data has been released from the Kaiser Commission on Medicaid and the Uninsured (KCMU) and the Georgetown University Center for Children and Families on Children's Health Insurance Program (CHIP) type and children's upper income eligibility limit for Medicaid/CHIP. Also new from KCMU and the Center for Children and Families is information on premium and co-payment amounts and requirements in both Medicaid and CHIP. 

Program Type and Upper Income Eligibility Limit for Children's Coverage as a Percent of the Federal Poverty Level (FPL), January 2011. 

Premium and Copayment Requirements for Children, January 2011. 

Judge upholds health law's coverage requirement 

By: Brent Kendall

Wall Street Journal

February 22, 2011

U.S. federal court judge Gladys Kessler in Washington, D.C. has become the third judge to uphold the constitutionality of the new health care law's health insurance mandate. The judge granted the government's motion to dismiss the case on the grounds that Congress is within the bounds of its Commerce Clause authority to require individual purchase of health insurance because the net result of those individual decisions not to purchase coverage affects the national health insurance market. The legal challenge to the constitutionality of the health care reform law is now beginning to move to the federal appeals courts in several states. 

Poll: 1 in 5 Americans believe health reform was repealed 

By: Sarah Clune and Lea Winerman

PBS Newshour

February 24, 2011

According to the latest Kaiser Family Foundation Health Tracking Poll, more than one in five Americans (22 percent) believe that the health care reform law has been repealed and 26 percent aren't sure whether it has or not. In a recent interview Drew Altman, president of the Kaiser Family Foundation, explains the misunderstanding as potentially the result of people seeing headlines about the largely symbolic repeal vote in the House of Representatives but have not dug more deeply into this issue. There continues to be a public divide along partisan and ideological lines about health reform; however, according to the poll some of the major provisions, such as the Medicaid expansion in 2014, are extremely popular among the American people.  

View the poll.     

The Catalyst Center is a national technical assistance and research center

dedicated to working with states and stakeholder groups on

 improving health care insurance and financing for

Children and Youth with Special Health Care Needs (CYSHCN).

For more information please visit us at www.catalystctr.org or

 contact Meg Comeau, Project Director at mcomeau@bu.edu.

The Catalyst Center is funded under grant #U41MC13618 from the

Maternal and Child Health Bureau, Health Resources and Services Administration