Just as everyone was preparing Thanksgiving dinner, the state of Wyoming released its version of Medicaid expansion – called the Strategy for Health, Access, Responsibility, and Employment (SHARE) program. As is in vogue with this round of Medicaid expansion proposals, this one will require a Section 1115 Medicaid waiver, but unlike some recent submissions, Wyoming’s proposal looks to me to be very much in the ballpark for what federal CMS is likely to approve – though, as always, some details would need to be worked out.
Of course, the proposal will have to go to the legislature for approval, and the waiver application will require public comment at both the federal and state level. But if the legislature gives the thumbs up, this could move quickly at CMS, and its release underscores that the Mountain West is the hotspot right now for further progress on Medicaid expansion. Coverage would likely begin for 17,600 persons in January 2016.
So lets take a look at the basic outline of the plan and how it compares to waivers in other states.
• Wyoming is not doing Arkansas. As I have blogged about before, every state has unique market circumstances, and it doesn’t make sense to assume that all states will do premium assistance and follow Arkansas’ lead to put new enrollees into the marketplace. Wyoming’s plan builds on its existing Medicaid delivery system, which, according to the state, has robust provider participation.
• Like Iowa, the plan would charge premiums for those above the poverty line, with a reduction in premiums for those who “complete certain health challenges”. It’s not entirely clear what those would be. In Iowa, at least initially, its an annual health assessment. The premiums themselves would be charged to those above the poverty line – as Iowa and Pennsylvania received approval to do. Arkansas has a pending request but the amount may be higher than what CMS is comfortable approving. (Note: CMS has been using as a rule of thumb analogous levels for persons receiving tax subsidies in the marketplace.)
• The plan uses the full flexibility in Medicaid to charge cost-sharing and models benefits on a commercial package. Here we will need to see the fine print, but it looks to me that the state does not intend to seek waiver authority in this area, except for premiums as noted above. Again, I have mentioned before that there is a substantial amount of flexibility to do cost-sharing under existing Medicaid rules (even though copays may deter folks from accessing needed services), and the state of Wyoming seems to have figured this out! (Premiums, however, always require a waiver because they are the price of admission.)
• New enrollees would be linked to a “work assistance benefit” but their Medicaid eligibility would not be affected. Pennsylvania famously went down the path of linking job training to Medicaid enrollment and federal CMS rightly insisted that it be dropped. Utah and Indiana are also investigating this linkage. Again, fine print needed here, but the state seems to be approaching the issue in a way that could be workable.
I am certainly not the right person to opine about what the legislature may do, but let’s hope that they give speedy approval to the Governor’s plan. Waiver negotiations should move swiftly with this one with CMS.