SANTA FE – Supporters call it a way to promote personal responsibility.
Opponents have called it cruel.
But beneath the rhetoric, it’s clear the proposal to revise New Mexico’s Medicaid program has the potential to change health care for thousands of residents, including people with disabilities.
More than 40 percent of New Mexico’s population is covered by Medicaid – or about 900,000 children, pregnant women, low-income adults and people with disabilities – and the state spends about $1 billion a year on the program. The federal government chips in billions more through matching funds.
Gov. Susana Martinez’s administration, which says the state Human Services Department cannot afford to pay its growing Medicaid bill, is seeking federal permission for a host of changes to the program. Those changes include the imposition of premiums and copays on more of those covered by Medicaid, and some benefits could be curtailed. For example, some Medicaid patients would have to pay premiums starting at $10 a month and copays starting at $5 for a doctor’s visit.
The changes would not substantially reduce the number of those eligible to receive benefits, which range from a single adult making less than $16,650 annually to young children in a household with $60,000 in earnings.
Martinez’s administration contends the proposal would help promote personal responsibility, control costs and improve the coordination of care. It would also create incentives for people to seek less-expensive preventative care, the state contends.
“We continue to receive an appropriation that’s insufficient to run the program as it exists today,” state Human Services Secretary Brent Earnest told lawmakers in September.
The New Mexico Center on Law and Poverty, among other opponents, says the proposed changes would discourage people from seeking health care and worsen the financial burden on low-income families who need the help, especially if they have chronic conditions. The proposal leaves a variety of questions unanswered, the center said, and a Democratic lawmaker described the changes as “cruel.”
“These cuts can’t be taken lightly,” said Abuko Estrada, staff attorney for the Center on Law and Poverty. “They reach to patients and reverberate throughout our entire health care system and the state economy.”
If approved by the federal government, the changes would go into effect in 2019.
There is, however, a potential wild card. The process could be interrupted if Congress repeals the Affordable Care Act and reshapes the health care landscape.
The state Human Services Department is accepting public comment on the proposal through 8 p.m. Oct. 30, and public hearings are scheduled throughout the state this month.
Here are some of the proposed changes:
Under the “Centennial Care 2.0” proposal, someone above the poverty level – roughly in the range of $12,100 to $18,100 a year – would pay a monthly Medicaid premium of $10 a month in 2019, with a state option to push it to $20 a month in future years.
Households with more than one person would pay twice the premium. For example, a family of three just above the poverty line would pay $20 a month in 2019, with the potential for an increase to $40 in future years.
The premium would vary, depending on how far above the poverty level a person or household is. An individual making nearly $36,200 a year – the highest category, about three times the poverty level – would pay a $25 monthly premium in 2019 for the services he or she is eligible to receive.
Native Americans would be exempt. The state says it would also develop other exemptions to cover homelessness and allow for other “hardship waivers.”
No premiums are charged now.
Individuals above the poverty level – about $12,100 a year – would face new copay requirements. They’d pay $5 for basic office visits, $50 for hospital stays or outpatient surgeries and $2 for prescriptions.
They would have to pay $8 for medication if they opted for the brand-name drug when a generic was available.
They would also face an $8 charge if they visited an emergency room when they don’t have an emergency.
Preventive services would not be subject to copays.
Native Americans, people with developmentally disabled waivers and certain other categories of patients would be exempt.
The proposed copays for nonemergency use of the ER and getting brand-name drugs instead of generics would apply to Medicaid recipients regardless of income level.
The state would have the option of curtailing or eliminating dental and vision benefits for adults in Medicaid – if necessary because of budget limits. The state would develop dental and vision options that people could buy.
The state proposes to eliminate a rule that allows people to seek retroactive coverage if they’ve received care before enrolling in Medicaid. Now, people can request coverage for health bills in the three months before they enrolled.
About 10,000 people, or 1 percent of the Medicaid population, requested retroactive coverage in 2016.
Native Americans and people in nursing homes would continue to be eligible for retroactive coverage.
The state argues that retroactive coverage is no longer necessary because of other changes in the health care system. Most hospitals and safety-net clinics are able to conduct presumptive eligibility on site, the state says.
The Center on Law and Poverty says retroactive coverage protects families from medical debt. There may be medical hardships or other conditions that prevent people from applying for Medicaid right away, the center contends.
The state wants to transition people off Medicaid more quickly when they get a new job or pay raise that makes them ineligible for coverage. The transitional program is offered to parents and caretakers who make less than 47 percent of the poverty level but then get a new job or pay raise.
Even without transitional assistance, the state says, the parents and caretakers would still be eligible to receive subsidies under the Affordable Care Act to buy private insurance.
The Center on Law and Poverty contends the transitional aid would ensure continuity of care as families move out of deep poverty.
A pilot program would provide prenatal and postpartum care – along with early childhood services – for women in two to four New Mexico counties. Providers would visit the women in their homes.
The goal would be to reduce preterm births, low-weight infant births and similar health challenges.
National research also shows home visiting increases school readiness, cognitive development, parental engagement and parent-child bonding and produces better maternal and infant health outcomes, according to the Pew Center on the States.
The state proposes to begin coordinating care before an inmate is released from custody so that treatment, therapy and other health care can continue or start right away.
The state is seeking to allow providers to charge a $5 fee if a Medicaid patient misses three scheduled appointments without prior notification.
Supporters say far too many Medicaid patients skip appointments, hurting patients who need those appointments and providers who are unable to see patients – and don’t get paid – during that time.
The state proposes to shift parents and caretakers who make at least 47 percent of the poverty level to a less expansive benefit package, similar to the standard Medicaid coverage they get now but with some limits on occupational therapy and no coverage for hearing aids.
Adults above the poverty level who don’t have children already are on the “alternative benefit plan.”
The state proposes to add vision coverage to the alternative benefit package.