Advocates worry Medicaid plan will cause the most vulnerable to be kicked off rolls, say ‘medically frail’ designation is inconsistent

As Kentucky moves toward implementing a stricter Medicaid plan, a group of providers, consumers and health advocates say they worry that its penalties, work rules and “onerous reporting requirements” will cause people to lose their coverage, especially those in the state’s most vulnerable populations.

The group participated in a Dec. 5 Insure Kentucky news conference. Insure Kentucky, led by Kentucky Voices for Health, is a coalition of nonprofits that promote policies to improve access to care for all Kentuckians.

The state calls its new Medicaid plan Kentucky HEALTH, for “Helping to Engage and Achieve Long Term Health.” It is also referred to as the “waiver,” since it is implemented through a waiver of normal Medicaid rules.

Among other things, the plan will require “able-bodied” beneficiaries to work, volunteer, participate in job training or go to drug treatment at least 80 hours a month, and then report the hours. Failure to report would result in loss of coverage, though it could be regained by taking a course in financial or health literacy.

The original version of the plan was vacated in late June just days before it was set to roll out. U.S. District Judge James Boasberg of Washington, D.C., ruled that, among other things, Health and Human Services Secretary Alex Azar had not fully considered the state’s projection that in five years under the plan the state’s Medicaid rolls would have 95,000 fewer people than without the plan.

Federal officials re-approved the plan Nov. 20. It is tentatively set to start April 1, with the work and community engagement requirements to be phased in regionally, but more legal action is expected.

Krista Seymour, a freelance television producer, said that while she was able to work and had steady employment, her work schedule varies each month, often because a medication she takes for thyroid cancer makes her too sick to work. She said she must take the medicine for the rest of her life, or die.

Seymour said she has applied for medically frail status, but has been denied twice because the state says she’s not frail enough to qualify. But Seymour says: “I cannot get anybody to actually give me a name or a criteria of what actually meets a medically frail designation.”

Until Kentucky HEALTH is implemented, there is no official “medically frail” status.

Ramona Johnson, president and CEO of Bridgehaven Mental Health Services, said her organization has experienced similar difficulties in getting some of their members a “medically frail” designation.

“We’ve been advised on more than one occasion that anyone who is diagnosed with a severe and persistent mental illness will automatically be considered medically frail and therefore exempt from the work or community engagement requirements, but we really have not found this to be true with any consistency, and we’ve been submitting information on our members for several months,” she said. “The managed-care organizations that we work with are receiving denials of medically frail status on some of our members, all of whom have a severe and persistent mental illness.”

Johnson said her organization supports work programs for their members, but would like to see the requirements be based on a person’s capacity to work, not a set number of hours. She said many of their members work in jobs that are tailored to their abilities, and they simply can’t manage a 20-hour work week. In addition, she said the reporting requirements would be an issue for her members.

“For those of our members who can and do work, the 20 hours a week or the 80 hours a month expectation is really very arbitrary and quite unrealistic,” she said. “When they lose Medicaid coverage as a result of this, then we have a group of very vulnerable people who are at risk of becoming symptomatic without treatment.” She added that research shows that when this happens, people with severe mental illness often end up in the emergency room or jail, or homeless.

Andrea Miller of the Kentucky Coalition Against Domestic Violence voiced concern that victims of domestic abuse will have to self-report and identify as a victim to get a medically frail designation.

Doug Hogan, spokesman for the Cabinet for Health and Family Services, said in an e-mail that there is an appeals process for people who believe they are inappropriately denied a medically frail designation

Hogan said there are three ways to be designated as medically frail: through an automated tool based on claims data; a provider’s attestation for medical or mental-health conditions that don’t have adequate claims data; or through self-attestation if the person is chronically homeless, a victim of domestic violence or if they have difficulty completing one of the “activities of daily living.”

He added that providers have access to an online guidance for filling out the attestation forms, which  includes a long list of conditions that would qualify as medically frail.

“To be clear,” he said, “Medicaid sets the state policy, and the MCOs [managed care organizations] administer according to policy, so that practices are consistent across the state.”

The three organizations that filed suit against the waiver are expected to file an amendment to their case soon. Cara Stewart, an attorney with the Kentucky Equal Justice Center, one of the three organizations that filed the lawsuit on behalf of 16 Kentucky Medicaid recipients, said last week that they were working on amending their complaint, but first had to check with all of the plaintiffs since some of their circumstances had changed since the suit was filed.

Stewart is hopeful the plan can be blocked again. “It’s hard to expect a different result with everything the same,” she said.

Emily Beauregard, executive director of Kentucky Voices for Health, said “This waiver is nearly identical to the original plan with the same types of barriers and red tape, and completely ignores new evidence that reporting requirements only work to reduce coverage.”

Beauregard was referring to the more than 12,000 people who have fallen off the Arkansas Medicaid rolls since the state implemented its work and reporting requirements, as well as a recent report that shows 10,000 Supplemental Nutrition Assistance Program (formerly food-stamp) recipients in Kentucky have lost this benefit since the state implemented similar work and reporting requirements.