Feb. 22 - Medicaid Expansion Advances

Dear Readers:

Here are two articles on the bipartisan bill to expand Medicaid.  "Medicaid Expansion" becomes something of a misnomer after Jan. 1, 2016, at which point all eligible would be required to find a private insurance policy on the exchange, with the premium paid by Medicaid.  If the reimbursements paid by the private insurance are higher than Medicaid, this will be good news for medical providers.  However, if the premiums cost the government more than Medicaid for the same people, you have to wonder how the extra cost is covered, particularly once the state has to kick in 10% of the program cost (starting in 2017).

Mark Fernald





Details of Medicaid expansion plan emerge


by Kathleen Ronayne,   concordmonitor.com,   February 12, 2014


The bipartisan group of senators behind a Medicaid expansion deal announced last week said they’ve created a system unique to New Hampshire that will give low-income people access to health care while increasing health care competition and decreasing uncompensated care costs.

“I think the federal government could’ve built a model much like we’re building now for the whole thing and been better off,” Senate President Chuck Morse, a Salem Republican, said in a briefing with reporters yesterday.

Lawmakers have been working for more than a year on legislation to provide new health insurance coverage to more than 50,000 low-income people, made possible by new federal dollars under the Affordable Care Act. But in the past, both parties were unable to come to an agreement, even during a two-week special session held in November dedicated to Medicaid expansion.

This bill would give premium subsidies to about 12,000 new people with employer-based health plans. An estimated 45,000 additional people would get federal money to help them buy plans on the insurance marketplace. The expansion plan backed by the federal government would put these people into existing Medicaid programs, so New Hampshire needs a waiver to use the money for private plans instead.

Senators from both parties said yesterday that they’re confident their caucuses will support the bill, which Republicans are declining to call Medicaid expansion. Instead, the bill calls the plan a “health protection program.” A full version of the bill should be available today, and the Senate Health, Education and Human Services committee will hold a hearing Tuesday.

In addition to Morse, the two Republicans sponsoring the expansion are Senate Majority Leader Jeb Bradley of Wolfeboro and Sen. Bob Odell of Lempster. On the Democratic side, Sens. Peggy Gilmour of Hollis, Lou D’Allesandro of Manchester and Senate Minority Leader Sylvia Larsen of Concord support the legislation.

The Democratic-led House has been supportive of Medicaid expansion, and the senators said they believe the House will support this new bill. Gov. Maggie Hassan endorsed this expansion bill in her State of the State address last week and reaffirmed her support yesterday.

For the 45,000 people not on employer plans, the bill would provide coverage in several steps and could take that coverage away if the waivers aren’t approved. These newly eligible people would enter into the existing Medicaid managed care program July 1 of this year.

If the state does not receive a waiver by March 31, 2015, the program will end and those people will lose coverage June 30, 2015. If the state does get a waiver, these people will remain on Medicaid until the end of 2015, then begin purchasing private plans on the marketplace in 2016.

Coverage under this bill will stop if federal funding dips below 100 percent. The federal government only plans to fully fund the program through the end of 2016, dropping to 90 percent and then lower. This means the next Legislature will have to reauthorize the bill in order for coverage to continue.

With much of the bill’s success hinging on waivers, Bradley said he is confident that New Hampshire has produced a bill that, while unique, will be accepted by the federal government. Iowa and Arkansas have received waivers for similar plans, he said. (Arkansas’s plan is now facing a challenge from Republicans on reauthorization, the New York Times reported this week.)

“This is, I think in terms of reform, pushing the envelope more than other states, but . . . we’re not designing it to fail, let’s put it that way,” Bradley said.

Putting more people on health insurance plans will decrease uncompensated care payments that drive up everyone’s health care costs, he said. This plan will also likely bring the Medicaid managed care providers onto the exchange, creating more competition. (The state cannot get a waiver with only one provider on the exchange.) The bill also includes “personal responsibility measures,” like requiring eligible unemployed adults to seek help securing employment.

The bill also seeks a waiver to get more money from the federal government on Medicaid services not already being reimbursed, such as substance abuse treatment or care for the incarcerated. To get the waiver, New Hampshire must show it’s pushing the trend of drug usage down. This extra money will also help complement the state’s mental health care system, Bradley said.

Overall, the senators from both parties expressed optimism about the bill’s future.

“I think it’s headed in the right direction, and now we have to convince the people in our parties that it’s the right thing to do for the state of New Hampshire, and we’ll do that I think,” Morse said. “Let’s get the bill out so we can have the public tell us what’s right and wrong with it.”

Larsen said that the dialogue between the two parties has been “healthy,” and the bill has much for Democrats to like.

“We’ve moved the interests of everyone to reach a solution that hopefully has widespread support, that provides and meets our goal – and everyone’s goal – of improving access to health care for what are mostly low-income, working people in our state.”

Hassan again expressed her support for the bill yesterday in a statement by urging both chambers to pass the bill.

“I thank Senators from both parties for their efforts to reach common ground on health care expansion, which will boost New Hampshire’s economy, reduce cost-shifting on businesses and improve the health and financial well-being of our families,” she said.


Correction: A previous version of this article incorrectly stated which Senate committee will work on the bill. The Senate Health, Education and Human Services committee will hold a hearing on the bill Tuesday.





NHPR News Primer: The Latest Medicaid Expansion Plan

by Todd Bookman,   nhpr.org,   February 13, 2014

Full details of a Senate plan to expand Medicaid under the Affordable Care Act are out.


(You can read the bill here.)

Let’s take a stab at simplifying the proposal:


Individuals who make less than 138% of the federal poverty level, or roughly $16,000 a year, could get health coverage through Medicaid starting July 1st. (The income threshold is higher for families.) Estimates vary, but in New Hampshire we are talking somewhere around 40,000-50,000 people.

These new enrollees would select from one of three Medicaid managed care companies, called MCOs. The state has contracts with these private organizations, which basically manage administration and function like other insurance carriers.


Starting in January, 2016, all those new enrollees would transition into the exchange (healthcare.gov) to select their preferred coverage plan. The federal government would still pay for everything, but this system, in theory, provides more choice for people. Hospitals and doctors like it, too, because their reimbursement rates are usually higher with private insurance.

New Hampshire lawmakers call this part of expansion the ‘premium assistance program’.


Ah yes, HIPP, the Health Insurance Premium Payment program. HIPP already existsin New Hampshire, but is rarely used despite its costs savings.

It works like this: anyone who qualifies for Medicaid but already gets insurance through a job (or a spouse’s) stays on that private insurance. Medicaid picks up the costs for any out-of-pocket expenses, including a worker’s share of the premiums, as well as deductibles and co-pays.

In New Hampshire right now, HIPP is voluntary, meaning people can just hop onto Medicaid and ditch the employer-sponsored insurance if they want. But under the proposed expansion plan, anyone eligible for employer-sponsored private coverage would be mandated to stay in that private coverage.

We’re talking roughly 12,000 or so people.


Yes, this entire plan ends December 31, 2016, which is also the day the federal government no longer funds the expansion at a full 100% of costs.

Future lawmakers would have to renew or revise the plan, or perhaps come up with an entirely new system.


First, a promise from the federal government. If it fails to pay for 100% of costs through 2016 as outlined in the Affordable Care Act, New Hampshire immediately repeals the expansion plan.

Second, if the federal government doesn’t give its permission for the proposed ‘premium assistance program,’ the state cancels Medicaid coverage for newly eligible recipients as of June 30, 2015.

The feds get until March 31, 2015 to decide if they like the proposed plan. One key measure they’ll look at is if this entire package actually lowers costs. If it doesn’t, expect a rejection letter.


The state needs permission from the feds to implement the private insurance option for Medicaid.

But in a push to further reform the entire Medicaid system in New Hampshire, there are other waivers written into the bill. They are called 1115 Demonstration Waivers, and they have the potential to dramatically change how Medicaid provides and pays for health insurance. Senate Majority Leader Jeb Bradley (R-Wolfeboro) says an 1115 waiver could save the state tens of millions of dollars in the future by reforming how services like mental health and inmate health care get paid for.


Both Republicans and Democrats in the Senate say they are behind the plan, so it may see little resistance. House Democrats are also likely to back the idea, and Governor Hassan has said she is on board. 

But compromises on expansion have come close in the past--most recently last November during a special legislative session--so nobody is counting on this as a done deal yet. And then of course, the feds need to give the okay.

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