Lawmakers remove enrollment cap in HIP redesign. Advocates urge them to reconsider other policies

A House committee Tuesday removed a controversial enrollment cap for the Healthy Indiana Plan, or HIP.

House Public Health Committee Chair Brad Barrett (R-Richmond) removed the enrollment cap from Senate Bill 2. He said the 500,000 person limit initially proposed in the Senate was “arbitrary.”

“The whole substance of a bill is to initiate this ‘right-sizing,’ if I can borrow that term, and initiate programs and policies that will help completely align those that need to be in this program with those that are in this program,” Barrett said.

The only policy still aimed at overhauling Indiana’s Medicaid expansion program reintroduces the previously halted work reporting requirements to HIP. But, other policies — including the enrollment cap and lifetime eligibility limits — could come back later in the legislative session as lawmakers continue working on the bill

Medicaid members and advocates thanked lawmakers for removing the cap — but they still want lawmakers to reconsider other policies in the bill.

Work reporting requirements

Work requirements position employment as a condition of eligibility. SB 2 would require people on HIP to work a “monthly average” of 20 hours per week.

Lawmakers said there are currently several exceptions, such as receiving unemployment, volunteering or being in a treatment program for substance use disorder. They also said there are a number of exceptions that need to be added as the bill moves forward, including being a full-time student.

However, Medicaid members and advocates aren’t necessarily concerned they won’t meet the requirements. Most Medicaid recipients already work or qualify under one of current exceptions. They point to past communication issues with the Indiana Family and Social Services Administration and worry errors and paperwork will cause Hoosiers who meet the requirements to lose coverage.

Medicaid experts say there's a history of Indiana Medicaid being complicated. It’s described as “notorious” for being difficult to navigate and stay enrolled in. Work reporting requirements were previously revoked in Indiana because they led to a loss of coverage.

Susan Brackney is a full-time, self-employed writer and a HIP member. She said this policy is built on a preconceived notion about who is in the HIP program.

“I'm a productive, tax-paying member of society,” Brackney said. “I help care for my elderly parents. I volunteer every Sunday. … I work really hard and it is because of the Healthy Indiana Plan that I am well enough and stable enough to do the stuff that I do.”

Brackney said HIP has been life-saving for her.

“When I hear about SB 2 and similar bills, it almost feels like some folks don't care whether I live or die,” Brackney said.

And for many members, losing coverage is actually matter of life and death.

Eliza Brader is a consultant who owns a small business. She has a masters in policy analysis and works on issues related to Medicaid. She’s also enrolled in the HIP program, specifically under what is called the “medically frail” program because of her chronic condition, Ehlers-Danlos syndrome or EDS.

One of the exceptions to the work reporting requirement is for people who are not physically or mentally able to work.

Brader said as written, she’s not sure if she’ll actually be included in the exception.

“It's not actually clear what the process is for being determined as medically frail,” Brader said. “That's always been a problem. Since the program was created, you cannot ask to be medically frail. Your doctor cannot ask. The state randomly determines when you are medically frail.”

To treat her EDS, she has a pacemaker and takes a medication that the withdrawal from can be deadly. She said she can’t afford to pay for those things out of pocket.

However, lawmakers said they think work requirements could lead to a more appropriately-sized program so Indiana can direct resources toward people who need them more.

In order to implement the work reporting requirements, the state will have to take on the additional administrative burden of the checking which will increase the cost of the program.

Hoosier Action’s Tracey Hutchings-Goetz said the COVID-19 public health emergency gives Indiana a lot of information about how much administrating the complicated parts of the program actually costs the program.

“During the pandemic when the program was more streamlined and enrollment increased by 25.6 percent, the cost of the program remained flat,” Hutchings-Goetz said.

There are only two states that have any experience with work reporting requirements, Arkansas and Georgia, and both appear to be scaling back their interest in work reporting requirements. Hutchings-Goetz said Georgia voluntarily stopped its monthly work reporting requirements due to cost.

READ MORE: Experts, advocates challenge misinformation from lawmakers on Medicaid, HIP overhaul bill

Increased eligibility monitoring

Medicaid members and advocates raised concerns about a provision in the bill that would require FSSA to review eligibility criteria more frequently.

Some of the reviews would be required on a quarterly basis, while most would be required monthly. The agency would look at information like income, family composition and payments members may receive through things like child support.

FSSA Secretary Mitch Roob said the agency has already begun quarterly eligibility reviews for 47 percent of Indiana Medicaid recipients, and he disagrees.

“That is all done electronically,” Roob said. “We may have to augment some of our vendor contracts, but we will not need to add additional staff.”

However, that isn’t supported by the bill’s fiscal note. It said the eligibility reviews will significantly increase administrative costs. It said the costs are “indeterminate” and the policies will likely increase workload beyond “existing staffing and resource levels.”
 

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Lawmakers said that FSSA would compare Medicaid member information with data from other state agencies to verify their eligibility for the program. If something comes up, lawmakers said that would start a redetermination process.

Brader said this is going to lead to more people being forced to do redeterminations more often — and lead to more people who are eligible for various Medicaid programs losing coverage.

“The fact of the matter is if somebody like me, who has a master's degree and understands Medicaid policy, can get kicked off the program multiple times, despite trying to meet all requirements, how are we going to expect anybody else in the state to be able to do four of those redeterminations a year?” Brader said.

Medicaid advertising, marketing ban

SB 2 would also codify FSSA’s decision to no longer allow advertising or marketing for Medicaid. Roob said the goal was to contain Medicaid enrollment growth following the COVID-19 public health emergency.

However, some Medicaid advocates raised concerns about the lack of clarity around what that ban includes.

Tom Crishon, chief legal counsel for the Arc of Indiana, said the ambiguous language in the bill could have unintended consequences, especially for nonprofits and advocacy groups.

“Organizations like ours do not financially benefit from Medicaid enrollment,” Crishon said. “Instead, we provide a vital resource to inform people about government programs designed and funded to provide these critical services.”

Rep. Maureen Bauer (D-South Bend) said it raises a question about what state agencies would be allowed to do under the language.

“As I read the bill, it says no state agency can advertise or otherwise market the Medicaid program,” Bauer said. “I think back to when we had the Medicaid unwinding and how we sent letters to everyone informing them of this unwinding process. We promoted it in many of our newsletters or pieces of mail.”

Crishon said lawmakers need to strike a balance between marketing and education.

“Clarifying the difference between marketing and education ensures that organizations like the Arc of Indiana can continue providing necessary general education to people with disabilities and their families,” Crishon said. “Additionally, ensuring that critical nonprofit entities are exempt from the prohibition, for instance, nonprofit organizations or advocacy groups that provide general information about or education about Medicaid eligibility and enrollment.”

Presumptive eligibility

Another significant change in the bill would affect presumptive Medicaid eligibility.

The goal of presumptive eligibility is to make sure people who appear to be Medicaid-eligible have immediate access to health care by providing short-term health coverage.

SB 2 would introduce stricter standards for hospitals and create a three-strikes policy for qualified hospitals. That means each patient considered presumptively eligible who does not qualify for Medicaid would count as one strike.

The Indiana Hospital Association said this policy is too strict and would ultimately result in no one conducting presumptive eligibility.

Lawmakers discussed leaning more on the program’s retroactive coverage rather than the presumptive eligibility process. Retroactive coverage is when someone qualifies for a program and receives coverage for past services, to a certain extent.

David Craig, a professor at Indiana University who studies Medicaid, said presumptive eligibility can also act as an “on-ramp” for people to get coverage.

“This takes people out of the cycle of going to the emergency room, having discontinuous care and expensive coverage,” Craig said. “As we think about presumptive eligibility versus retroactive coverage, we really need to think about the ways that hospitals have qualified people for this program, and then what matters is continuity. People need continuity.”

The House Ways and Means Committee will consider the bill next. Lawmakers on the House Public Health Committee said they plan to propose amendments on the advertising ban and work reporting requirement exceptions.
 

WFYI's Ben Thorp contributed reporting to this story.

Abigail is our health reporter. Contact them at aruhman@wboi.org.