Monday, September 9, 2013

The questionnaire that will determine whether beneficiaries get "private option" plans or traditional Medicaid

Posted By on Mon, Sep 9, 2013 at 5:44 PM

Under the so-called "private option" for Medicaid expansion, most newly eligible Arkansans will shop for private health insurance, with the government picking up the tab for their premiums. But ten percent of the newly eligible population — the ones predicted to have the most medical need and risk the highest costs — will go to the traditional Medicaid program. 

This isn't something that beneficiaries have an option on. If they are part of the 90 percent predicted to be relatively healthy, they have to use the "private option" private plans. If they're part of the 10 percent "medically frail/have exceptional needs," they have to go to the traditional Medicaid program. How will DHS make this determination? When new beneficiaries sign up, they will fill out a 12-question questionnaire, which includes self-assessments of health, and questions on living situation, hospitalizations, doctor visits, and previous conditions. The Department of Human Services provided me a copy of the preliminary version of the questionnaire, which you can see here . Spokesperson Amy Webb said that they will continue to revise and tweak it going forward.  

DHS has worked with researchers from the University of Michigan and the federal Agency for Healthcare Research and Quality to develop this screening tool. An algorithm will be applied to identify the top ten percent of the newly eligible population in terms of expected cost and medical need. The goal is to avoid having to coordinate additional services between Medicaid and the private carriers, which may not provide sufficient coverage for this medically needy population; it should also make for a less risky pool in the marketplace, helping to keep premiums down. 

The screening tool targets a number — ten percent — rather than identifying people who meet a set definition of "medically frail." This drew concern in a  letter submitted to the feds   by a group of health-related organizations, penned by Joan Alker at Georgetown Center for Children and Families and Judy Solomon from Center on Budget and Policy Priorities, commenting on the Arkansas plan: 

Determining in advance how many people in a newly covered population will be medically frail is inconsistent with the Medicaid statute and regulations, which require all who meet the definition to be included regardless of their expected health care costs. Some individuals with disabilities, for example, who should be considered medically frail under the regulatory definition, may not have high expected healthcare costs, but they are still entitled to a determination that they are medically frail. Arkansas should confirm that it will treat all individuals who meet the definition of medically frail in accordance with the requirements of the Medicaid statute and regulations, not just those who are identified based on an arbitrary predetermined percentage of the population.

I asked DHS about this issue; they responded with a statement that they will not solely rely on advanced screening to make "medically frail" determinations, and that the screening tool will also flag conditions outside of expected cost that would automatically qualify a beneficiary as medically frail. DHS statement after the jump: 


We will allow for real time, not just advance self-identification. This screener will be used for advance self-identification. We will develop a post-enrollment process once we complete the pre-enrollment screener. Indeed, we are going to do a better job than many other states identifying those with exceptional health care needs up front. Finally, and this is key, the algorithm — not yet final — will not rely solely on predicted health costs but has several automatic qualifying conditions, which are directly related to many disabilities.

All told, we believe we are using all available national data sources to develop a novel approach to population-based health needs screening that adds an important opportunity for Arkansas consumers to declare their needs and get appropriate services — an opportunity that we might have missed out on had the Private Option not passed.

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