SSA Launches A Stealth Assault on Medicaid Coverage for Children and Parents with Disabilities

As readers of Say Ahhh! know, children’s enrollment in Medicaid and CHIP is declining, and the number of uninsured children is increasing.  There are a number of factors at play, including a “see-no-disenrollment, hear-no-disenrollment” posture from CMS Administrator Seema Verma.  The Administrator is doubling down with an eligibility rule now under review at the Office of Management and Budget to “Strengthen the Program Integrity of the Medicaid Eligibility Determination Process,” which is likely code for more red tape that will result in further enrollment declines. The Administrator is not alone.  She’s been getting a little help from her friends at the Department of Homeland Security, who issued the public charge rule last October that has contributed to eligible families and children exiting Medicaid.  And in November, the Social Security Administration (SSA) proposed a rule that, if issued in final form, is likely to add to the Medicaid disenrollment count for both children and families.

SSA’s proposed rule would increase the number and frequency of Continuing Disability Reviews (CDRs) for children and parents receiving Supplemental Security Income (SSI). SSI is the program of cash assistance for individuals with disabilities with low incomes and assets. Receipt of SSI benefits is one eligibility pathway for children and parents to qualify for Medicaid.  An increase in the number and frequency of CDRs will likely result in loss of SSI benefits and potentially Medicaid coverage for low-income children and parents.

Currently, SSA conducts CDRs to determine whether an individual who receives SSI continues to meet the disability requirements of the SSI statute. The frequency of these reviews depends, among other things, on whether the individual has an impairment that SSA classifies as not permanent (medical improvement possible), such as epilepsy, in which case the CDR is at least once every 3 years.  If the individual has what SSA classifies as a permanent impairment (medical improvement not expected), such as muscular dystrophy or cerebral palsy, the CDR is at least once every 7 years.

Under the proposed rule, some children currently subject to CDRs every 3 years would be subject to a CDR every 2 years. And all children and adults currently subject to a CDR every 7 years would be subject to a CDR every 6 years instead.

The proposed rule describes some specific groups that would be subject to reviews every 2 years, including: children with cancer, anxiety, and speech impairments, as well as a new, age-based review at 6 and 12 years old.  The proposed rule would also subject some parents to more frequent CDRs. For example, some parents with cancer would be subject to more frequent reviews, as would “Step 5” parents (those who qualify for SSI following a determination that they cannot work, even in jobs that are different from previous employment experience).

SSA estimates that, by terminating eligibility for SSI benefits, the proposed rule will, on net, lower federal SSI payments by $0.6 billion over 10 years.  The estimate does not, however, specify how many children or parents are likely to lose SSI benefits or how many of these are likely to lose their Medicaid coverage as a result of eligibility churn.  Similarly, the proposed rule does not estimate the administrative costs to state Medicaid agencies and to the Centers for Medicare & Medicaid Services (CMS) resulting from this eligibility churn. In fact, other than a single reference to Medicaid as a source of health care for some beneficiaries, the proposed rule does not consider Medicaid’s role for individuals receiving SSI at all.

With a tip of the hat to my colleague Kelly Whitener who did the heavy-lifting, CCF submitted comments on January 31. We urged that the portions of the proposed rule relating to SSI be withdrawn and that SSA reconsider its proposals, taking into account the relationship between SSI and Medicaid eligibility and the likelihood that more frequent CDRs will lead to eligibility churn and loss of Medicaid coverage.  Medicaid beneficiaries, providers, managed care plans, and state agencies would all be affected by Medicaid eligibility churn that will likely result from more frequent CDRs, but SSA simply does not address these impacts.  While this is entirely consistent with Administrator Verma’s “see-no-disenrollment, hear-no-disenrollment” approach to Medicaid eligibility, children and parents with disabilities deserve better.