CQC to Governors: Keep Patients at the Center of Medicaid Changes


States are the laboratories of our democracy, and governors can provide critical leadership in addressing our nation’s health care challenges. Unfortunately, many governors across the U.S. are waging dangerous experiments with health care and Medicaid programs that threaten their states’ most vulnerable residents, attempting to radically reshape safety net programs through Section 1332 State Innovation and Section 1115 Medicaid waiver requests to the Centers for Medicare & Medicaid Services (CMS).

Some of these dangerous experiments include:

  • Instituting co-pays for non-emergency or “inappropriate” use of emergency room services, putting patients in the unfair position of being their own doctors and diagnosticians;
  • Adding new monthly premium fees for low-income patients;
  • Eliminating retroactive eligibility, an important protection for patients that covers medical bills incurred in the three months before a patient’s Medicaid application;
  • Instituting work requirements as a condition of coverage;
  • Cutting screening and diagnostic benefits; and many others.

As governors from across the country gather in Santa Fe, New Mexico for the National Governors Association (NGA) Summer meeting, Consumers for Quality Care (CQC) is asking them to carefully consider the impact their administrations’ Medicaid waivers will have on the neediest patients in their states.

CQC’s State Waiver Checklist can aid in that deliberation to ensure consumer care remains the focus of the any changes proposed in state Medicaid programs. We believe attention to the following areas will help achieve the best outcomes for residents of all states seeking to reshape their health care markets through waivers:

  • 1. Access

    No Barriers to Coverage: Does not impose unreasonable conditions for receiving health coverage, including work requirements, literacy provisions, and lockout periods for unpaid premiums.

    No Red Tape Burden: Does not impose cumbersome and time-consuming barriers to receive and maintain coverage like online-only reporting requirements for communities with low internet accessibility and penalties for not completing renewal forms.

    Functional Technology Infrastructure: Ensures fully tested and functional technology infrastructure ready for consumer use, including a comprehensive and well-functioning website, where consumers are able to submit all required information and payments, receive confirmations of their submissions, and are able to check the status of those submissions.

    Accessible Network: Requires coverage providers to have an up-to-date and easily accessible portal of in-network doctors and prescriptions.

    Prescription Drug Choices: Requires options to cover both generic and brand name medications.

  • 2. Cost

    Affordable for Consumers: Does not shift cost from the state, providers, insurers or drug companies to consumers.

    No Cost Increases: Does not increase cost sharing and/or premiums for consumers.

    Sets Out-of-Pocket Limits: Caps Medicaid out-of-pocket costs, including premiums, at 5 percent of the recipient’s total income.

  • 3. Quality Care

    Adequate Provider Networks: Ensures that networks are not so narrow that patients forego access to high-quality, life-saving care when needed. Ensures broad networks that include primary care and specialty care health care providers.

    Emergency Care: Includes emergency transportation and emergency department care

    Essential Health Benefit Coverage: Includes a comprehensive level of care for each of the 10 essential health benefit categories.

  • 4. Patients at the Center

    Benefits for Special Populations: Considers how reduction in corollary benefits, such as non-emergency medical transportation, might impact populations with certain conditions and special needs.

    Community Engagement: Convenes an advisory committee of local health care and consumer advocates to provide input during initial waiver drafting.

  • 5. Transparency

    Specific Estimates of Impact on Coverage and Services: Clearly outlines the implications of the waiver for consumers.

    Public Meetings: Holds at least three public meetings for state residents on the proposed changes and includes options for following via an online portal.

    Financial Implications: Includes waiver’s projected impact on the state’s budget.

    Sharing Comments: State and local comments should be shared publicly before being officially submitted to CMS.

Read CQC’s letter urging governors to carefully consider the impact these waivers will have on patients.

Click here for the CQC State Waiver Checklist.

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