Cause for Concern: Many fear they can’t meet Medicaid work requirement

Messenger-Inquirer (Owensboro, KY)

June 03--When it comes to her Medicaid coverage, Mary Ellen Guy feels like she's living in limbo.

Earlier this year, Kentucky received the nation's first federal Medicaid waiver, allowing the state to require able-bodied enrollees to participate in "community engagement" activities -- work, school, caregiving or volunteerism -- at least 80 hours a month or lose their health insurance.

The state's new regulations are set to begin July 1 in parts of Kentucky but won't roll out in western Kentucky until November.

When Gov. Matt Bevin's office released information about the waiver in January, Guy feared losing her benefits.

The Greenville woman can't meet the 80-hour work requirement -- as it is most often called -- because she cares for her parents, Anna and Harold Guy, who are in their 80s.

Until two years ago, Mary Ellen Guy worked in Chicago as a leasing agent for Wirtz Realty Corp., but she resigned to return home when her parents needed her.

Working, school or volunteerism are not options right now. Anna Guy suffered a stroke earlier this year and needs around-the-clock assistance. Besides, Muhlenberg County's economy does not offer many professional positions for someone with Mary Ellen Guy's experience.

Even if the state's new regulations allow her, as her parents' caregiver, to keep her Medicaid benefits, she disagrees with the waiver and its requirements.

"For me, (Kentucky's Medicaid waiver) is a travesty," she said. "It's wrong on so many levels. You take one of the most important things -- health care -- and dangle it in front of people like a carrot."

Risks for working residents

State officials expect 95,000 Kentuckians to roll off Medicaid within the next five years.

That number includes people who may transition to commercial insurance as well as those who may fail to comply with new state requirements, said Kristi Putnam, Deputy Secretary for the Cabinet for Health and Family Services and program manager for the Medicaid waiver.

Many who will lose benefits are already employed, according to the Center on Budget and Policy Priorities, a Washington, D.C.-based progressive think tank.

Most Medicaid recipients work, but they often face frequent job losses and fluctuating hours. Because of the instability associated with many low-wage jobs, the center estimates one in four enrollees may be at risk of losing benefits or experiencing interruptions in medical coverage each year because they will fail to be compliant.

"Approved and pending state work requirement policies are based on the assumption that people who want to work can find steady employment at regular hours," the national center reported. "This assumption is out of step with the realities of the low-wage labor market."

That is especially true in rural Kentucky, where the economy in some counties has not rebounded fully from the Great Recession.

Putnam said state officials have the authority to roll out the community-engagement requirement on a county-by-county basis. If a county's unemployment rates are high, the new requirements may be stalled.

"We know there are areas in the state that have challenges when it comes to job opportunities," Putnam said.

And, during the interview, she took issue with those who use the term "work requirements."

"Work is only one way to meet the requirement," Putnam said. The term community-engagement more accurately reflects the intent because people also can attend school, take care of their disabled children or volunteer at a park, for example.

Local concerns

Green River District Health Department officials have fielded lots of questions in recent months from anxious clients seeking answers about the new Medicaid waiver. At this early stage, the department's staff still struggles to understand the full impact, said Clay Horton, executive director.

In general, though, all able-bodied Medicaid recipients will see some changes. For example, they will have to provide documentation of work or volunteer hours.

"Some may have co-pays or be required to pay premiums," Horton said. "Also, some of their benefits, like dental and vision coverage, will shift to an alternative benefit plan called My Rewards, where the participant must earn dollars through completing education or community engagement activities."

Prior to the Affordable Care Act, some regional counties had uninsured rates as high as 22 percent.

"Our community suffered much under that reality," said Suzanne Craig, GRDHD's Daviess County Community Access Project coordinator. "We are sure there will be some obstacles, but we have confidence, given our past environment, that the community will rise to the challenge."

Last year, Medicaid clients made up about 30 percent of the health department's revenue. The biggest portion of those clients were children, pregnant women, parents and the medically frail.

"These groups shouldn't see as many changes to their coverage and requirements," Horton said.

Right now, the health department doesn't know of any direct impact to its revenue, but there could be an indirect impact if some clients lose coverage.

More than 13 percent of Owensboro Health Regional Hospital's net patient revenue comes from Medicaid, said Russ Ranallo, vice president of finance.

"We have patient financial advocates at the hospitals and clinics that assist our patients with applying for Medicaid coverage," Ranallo said. "We expect the reduction to be minimal."

Brandon Taylor, an Owensboro dentist and director of Community Dental Clinic, opposes the proposed My Rewards program. The Kentucky Dental Association and Dental Technical Advisory Committee are against it, too.

The My Rewards program -- which Putnam said will roll out statewide on July 1 -- requires recipients to engage in volunteerism, finish their GEDs, take smoking cessation classes and more to earn enough points to cover dental and optical needs, Taylor said.

In addition, recipients will be docked points if they go to an emergency room for anything not considered to be an emergency. Toothaches may fit in that category, Taylor said.

"So a possible scenario is that someone worked to accrue enough points through community engagement only to lose them when their face swells in the middle of the night due to an abscessed tooth. Now, they are unable to have the tooth extracted because they do not have enough points," he said.

Taylor wants emergency dental procedures excluded from the My Rewards program. "These procedures should be a guaranteed benefit to Medicaid recipients."

Lack of communication

Earlier this year, Mary Ellen Guy called WellCare, which provides her Medicaid coverage, looking for an answer to her question: Under the waiver, will she be able to keep her Medicaid benefits as her parents' caregiver?

WellCare representatives told her providing care at least 80 hours a month should protect her benefits. However, at the time, they offered no guarantee.

It's been hard to get answers, Mary Ellen Guy said, because agencies in charge of Medicaid aren't sure of the details yet.

She received a brief letter with no details months ago from state officials, which told Medicaid recipients to expect upcoming changes. But, since then, nothing.

"When something this major is going to change, it needs to be handled in a more organized way, and the communication should be handled better," she said.

Putnam said state officials wanted to get more information out before now.

However, in the state's defense, she said the federal government approved Kentucky's waiver on Jan. 12. Technology updates and policy refinements were needed before communication could start in earnest.

In the meantime, the Medicaid waiver staff enlisted the help of a citizen-engagement team that interviewed residents to learn what parts of the waiver were confusing and how the state could communicate better.

Putnam said state officials will focus on getting the word out during the next two weeks. "Communications are coming."

Renee Beasley Jones, 270-228-2835, rbeasleyjones@messenger-inquirer.com

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