Welcome to Part 2 of my musings about the state of premium assistance. Part 1 left us with the teaser that CHIPRA includes new premium assistance options, which the new health reform law incorporates and expands to all Medicaid beneficiaries as of January 1, 2014. So let’s take some time to explore where things stand with Title III of the CHIPRA law which is all about the integration of public and private coverage.

In our analysis of CHIPRA released in April 2009 we covered many of the key features of Title III the new law on p. 16. So I won’t cover old ground but will pick up with some updates.

First, CHIPRA required the GAO to do a report on state premium assistance programs. That report was released in January 2010. The report is a nice summary of where states are with respect to premium assistance, although many key questions remain unanswered.  As I have found doing my own research on premium assistance states often do not keep good data on the costs of their premium assistance programs and they rarely track what kinds of coverage families are receiving. Since some premium assistance programs (generally those authorized under waivers) require families to pay all of the cost-sharing that their private plan requires, we don’t know if these costs and benefit limits are preventing kids from getting the care they need.

But I digress. One of the most interesting aspects of the GAO report was that it was the first time that a 50-state survey has been done which asks states if they are subsidizing coverage under Section 1906 of the Medicaid law. This option allows states to require families to enroll in their group coverage if it is cost-effective for the state. All Medicaid beneficiaries who are enrolled in this coverage must receive wraparound benefits and cost-sharing subsidies. So this is premium assistance done right.

When I talk to state advocates who are thinking about pursuing premium assistance as a strategy, or are dealing with state policymakers who are thinking about it, especially if they are talking about pursuing a waiver, my first response is to say that your state may already be doing premium assistance through Section 1906 and it doesn’t need a waiver. So now we know – 29 states are operating this kind of program. So the GAO report is a good place to start when thinking about premium assistance.

Another feature of  CHIPRA’s Title III was that certain barriers to doing premium assistance that required federal statutory change were lifted. In particular, Medicaid and CHIP eligibility is now a “qualifying event” under federal law and plans have to offer a “special enrollment period.” These are terms of art that mean certain happenings (like a birth or a death and now Medicaid/CHIP eligibility) allow you to enroll in a group health plan even when it is not open enrollment. Previously, in most cases, families that became eligible for premium assistance would have to wait until their open enrollment period. Now they don’t.  And a child who loses Medicaid eligibility because their parents get a raise can be signed up for the employer’s plan right away and not have to wait for open enrollment.

My final point of the second part is that Title III also created a Working Group which will issue a report the Secretaries of Labor and Health and Human Services and has two substantive charges:
1) To develop a model coverage coordination disclosure form and;
2) Identify impediments to the effective coordination of coverage between group health plans and Medicaid and CHIP.

Federal guidance on the special enrollment periods and information on the Working Group is available here http://www3.cms.gov/CHIPRA/09_Section311.asp

The Working Group is having its first of two meetings this coming Monday, April 26th and yours truly is a member. If you have any suggestions or thoughts to share please email me in the interim at jca25@georgetown.edu.

And as you Rings fans have already guessed, Whither Premium Assistance has evolved into a trilogy. So you will have to wait until the final installment to learn more about the elusive 1906A……