Communities can coordinate to keep Oregonians insured despite new work rules, HR 1

Presenter: Cancer patients undergoing chemotherapy used to be exempt from Medicaid work requirements. The Trump administration says: Not anymore.

At the H.R. 1 Eligibility deep-dive webinar (Oct. 26), consultant to multiple Oregon coordinated care organizations, Cathy Kaufmann:

Cathy Kaufmann: We thought if you’ve got a diagnosis of cancer, you’re actively receiving chemo, you’ll automatically meet this exemption.

No, the new rule says it’s not enough. You’re going to have to have a way to prove that because you’re actively getting chemo, you can’t work or go to school. We’re not going to just assume that’s the case.

Inevitably, this is going to end up meaning there need to be some notes from providers or other ways to document that having this condition prevents you from being able to work.

Oregon is one of 26 states currently suing the federal administration around this new requirement, arguing that it goes against what was written in H.R. 1, what Congress stipulated.

So, we don’t know what the outcome of that will be. It’s possible it could be decided in November and December, leaving states very little time to figure out how to implement.

Now, I will say: For 2027, the CMS has said states are allowed to use self-attestation. So a lot of these scarier pieces of the rule won’t be as much of an issue for this current upcoming year, but will very much be a grave concern for 2028.

And of course, we’ll start implementing 2028 requirements in late 2027.

Presenter: Another threat to the entire healthcare ecosystem is what she called ‘churn.’ Cathy Kaufmann:

Cathy Kaufmann: Everybody, even if you meet an exemption, is going to have more frequent redeterminations regardless. For Oregon this is going to be  complicated because we have a couple of different, what are known as continuous eligibility waivers. We’ve got really wonky timelines for when the more frequent renewals requirement will go into effect here.

We have continuous eligibility waivers through the end of September, 2027. So that means kids who right now have either two-year continuous eligibility, or if they’re under the age of six, continuous eligibility until they turn six, they are all going to move back to one-year eligibility. And they’ll need to be renewed each year.

Other adults who have two-year continuous eligibility are going to move to renewal every 12 months. And our expansion adults, the ACA expansion population or MAGI (Modified Adjusted Gross Income) adults, they are moving to six-month redetermination.

So they’re, every six months, they’re going to have to prove whether or not they’re eligible and get all of their paperwork in or stand to lose coverage.

I think we’re all really focused on work requirements and appropriately so, ’cause that’s what’s going into effect first. But everybody should be very worried about more frequent renewals.

I used to run eligibility for the state of Oregon a decade or so ago (maybe a little bit longer than that), when we expanded coverage for kids and we put a lot of money into outreach and great partnerships with community-based organizations across the state to make sure families knew about healthy kids.

But I wasn’t seeing the enrollment numbers tick up the way I expected to. We quickly learned it’s because even though we were bringing in a bunch more new kids through the front door, we were losing them and their parents through the back door when it came to renewal time because so many people struggled to get through the paperwork process.

So, more frequent renewals always lead to what’s known as churn, which means people are still eligible but they lose their coverage ’cause they didn’t finish the application.

They go without coverage for a few months. Eventually we get them back in coverage, but not all of them. Some people simply lose their coverage even though they remain eligible.

We are going to see more of that when these new rules go into effect.

So to drive this home in 2023, 72% of people who lost Medicaid lost it, not because they weren’t eligible, but because they had difficulty completing the paperwork process. 72% of people who lost their coverage lost it because of the paperwork process. They were still eligible.

We have a little bit of a preview of what the impact is going to be, because Nebraska opted to implement early. They implemented the work and activity rules requirement May 1, rather than waiting until Jan. 1.

We have very, very early preliminary data through August showing that 14% of folks applying for the first time were denied, but not because they weren’t eligible, it was around proving the worker activity rules.

And 7% of people renewing lost their coverage because of the worker activity rules. I would expect this number to steadily tick up, this rate to steadily tick up, right?

We’ve got work requirements, they’re going to be a logistical nightmare for everybody. We have far more frequent renewals for everybody, twice a year if you’re a MAGI (Modified Adjusted Gross Income) adult, at least once a year for everybody else, even kids.

On top of all that, we also have something called ‘reduced retroactivity.’

Since the beginning of Medicaid, there has been a 90-day retroactive coverage period. That means, if I get into a car accident, I have no health insurance, I end up in the emergency room. They have to treat me no matter what. They save my life. They spend a lot of money doing it.

They help me get enrolled in Medicaid, I qualify, they can retro my coverage back 90 days. So that means all the care they provided to me before I applied and got enrolled into Medicaid can still be covered and the hospital can get paid.

Well, H.R. 1 changes the period of retroactivity and now instead of 90 days, it’s going to be 30 days for those MAGI adults and it’s going to be 60 days for everybody else.

So this is just another straw on that camel’s back, when it comes to hospital finances in particular. But we’re going to have increased number of people without health insurance, and we’re going to have a reduced period of retroactivity, even for those who do qualify.

Presenter: She was asked about how to help get the word out. Cathy Kaufmann:

Cathy Kaufmann: Getting the word out—messaging—is going to be really important. What works incredibly well is when communities come together and do some organizing together around this, so it’s not a bunch of different organizations doing a bunch of different things, but the community really coordinating to get the same messages and materials out to as many people as possible.

And that’s part of what the Jefferson Regional Health Alliance is doing. And I know other communities are having those conversations as well.

And we know that CCOs are talking to community partners, but take all those lessons that you learned during the pandemic when it came to doing outreach around the vaccine and reapply them here because a lot of the same rules apply.

Presenter: A comment from (a participant):

Participant: One of my plans is when I’m handing out H.R. 1 flyers to community members is, in case there are questions about, like, ‘Well, where can I get a job?’ Or, ‘Where can I volunteer?’ I will have a short list of local opportunities. So I just wanted to throw that out there. Also as a (Amazing)

So that’s been, it’s on my list and the Job Will Connections program is both volunteering and work. So that’s a great, a great tool if other people have Goodwills close to them.

Cathy Kaufmann: So that’s great. The volunteering will have to be documented so that the individual has something to give OHA. So that’s a good thing to remember.

And again, the vast majority of folks who need to meet work requirements aren’t going to have any trouble meeting them. They’re already working or doing something that qualifies, but for the few who won’t, it’s a fantastic idea to have some volunteer opportunities readily available to help them qualify.

A great thing for a community to be sharing with each other…

As far as other resources to be thinking about, so lots of different languages, for one-pagers, posters, etc., on the OHA page. So definitely, definitely go there.

But the other thing that I think will be really helpful, especially as we have limited resources across the state for application assistance and even the call center, I mean, a lot of people are going to be confused and have questions and need help, and we may not have all the help we wished that we had.

Don’t underestimate the value of self-help tools. We have the one eligibility system. Folks might just get stuck on one part and not necessarily need an application assistor to walk them through the whole process.

So communities coming together to make some self-help tools, I think, could be tremendously valuable. Even little videos of like, where am I supposed to upload? What does this letter mean? etc.

Presenter: The deep-dive webinar was convened by Oregon’s Office of Rural Health. We’ll end this story with one final comment:

Participant: Yeah, no, I’m still in shock that like refugees, asylees and other lawfully-residing non-citizens aren’t eligible for, like, fully-funded Medicaid and CHIP.

Like, I’m just, that’s, like, my main takeaway from this session, ’cause I’m just like, we live in, like, a sanctuary state. I’m sorry. I’m just at a loss for words and I was just like, I hope there’s, like, more resources for people that are undocumented. My heart just, like, goes out for them.

That’s just, that’s all I had to say.

Cathy Kaufmann: It’s a very understandable reaction and thank you for sharing it with everyone.

It’s very clear that we are in a period of time where the federal government does not wish to be a partner to states in expanding coverage or making sure everybody who needs health coverage can get it. That’s simply a statement of fact. And there will be consequences (Yeah) for human beings, for state budgets, for healthcare providers.

Presenter: States scramble to comply with new Medicaid requirements.  Early results from Nebraska suggest that people who are otherwise eligible are being denied because of the new (and more frequent) paperwork. A consultant to Oregon CCOs says communities should work together to help get the word out.