So as Tricia Brooks blogged about yesterday while I was taking the day off, CMS issued some interesting Q and A’s  last Friday on how a state might consider taking a premium assistance approach to expanding their Medicaid program.  The Q and A’s, to my mind, were a helpful contribution to the ongoing discussions in some states about this idea.

So what did CMS say? Perhaps subtle, but the main message here was that if states want to require Medicaid beneficiaries to participate in a premium assistance model (accessing Qualified Health Plans in the exchange), they will need a Section 1115 waiver. Such an option could be pursued as a state plan amendment if participation is voluntary.  CMS indicates that they will “consider approving a limited number of premium assistance demonstrations” that will end no later than 12/31/16 and be evaluated carefully prior to 2017 when State Innovation Waivers become available to states.

CMS also lays out some conditions for these proposals which include the following:

• Beneficiaries must have a choice of at least two QHPs;
• The state must ensure that the QHPs provide any necessary wrap around benefits and cost-sharing protections and must ensure that QHPs provide appropriate data;
• Are limited to individuals “whose benefits are closely aligned with the benefits available on the Marketplace” i.e. newly eligible adults.

While not required, CMS indicates that they would look favorably on a proposal which limits this approach to newly eligible adults between 100-133% of FPL. This sounds like Ohio to me.

A few other points to note – the Q and A’s make clear that these newly eligible adults remain Medicaid beneficiaries and remain entitled to all benefits and cost-sharing protections. This is important, and as is always the case in any Section 1115 waiver, all Medicaid rules continue to apply unless they are explicitly waived. For example, I assume that Medicaid transparency and public process rules, which I blogged about previously, would apply to these proposals going forward, though this is not explicitly discussed in the Q and A.

So all in all, some useful clarity here, and for state legislators who are talking about doing premium assistance, these Q and A’s should help to clarify the issue for any elected officials that are serious about extending coverage to more uninsured people in their states.   Now that CMS has put its cards on the table, it’s time for elected officials to stop jaw-boning the issue and decide whether or not to pursue this option.  Do they really want to bring home generous federal funding to help meet the healthcare needs of their constituents or not?