PROPOSED FREE CARE CHANGES
The Division of Health Care Finance Policy this month released proposed changes to the Uncompensated Care Pool (Free Care Pool). One definite change will be the name which will change from the “Uncompensated Care Pool” to the “Health Safety Net Trust fund”.
Summary of key points in the Health Safety Net Trust Fund proposed rules (subject to public comment and possible changes): “Health Safety Net – Primary.”
Uninsured people up to 200% of the federal poverty level (FPL) are eligible for The patient must also be ineligible for any medical assistance program. Someone eligible for MassHealth, Commonwealth Care or affordable employer coverage is not eligible for Health Safety Net – Primary. Someone eligible for Commonwealth Care who fails to enroll, will not be eligible for the Health Safety Net Trust fund. Someone enrolled in Commonwealth Care who fails to pay a premium, will not be eligible for the Health Safety Net Trust fund. This is a major change from current policy, and in effect adds pool ineligibility to the existing tax penalty under the individual mandate. Health Safety Net – Primary does cover someone enrolled in Commonwealth Care whose coverage hasn’t started. “Health Safety Net – Secondary.”
The Health Safety Net also fills in services for underinsured people up to 200% FPL. This “pool wrap” is called “Health Safety Net – Secondary.” This includes people with reduced benefit MassHealth programs, such as Healthy Start or CMSP. Those with inadequate private coverage, including Student Health and Young Adult Plans, can get coverage for deductibles and services excluded from their plans, but not co-pays. Co-insurance, which is included in some Young Adult Plans, is not mentioned as in or out. People in Commonwealth Care between 100%-200% FPL can get secondary coverage only for dental care. “Health Safety Net – Partial”
Partial Free Care for those 200%-400% FPL is replaced by “Health Safety Net – Partial,” with similar deductible rules as the current Pool. Totally revamped is medical hardship. Under current rules, eligibility doesn’t kick in until someone accrues over 30% of their income and disposable assets in medical bills. The new hardship standards are set on a sliding scale. Someone up to 200% FPL becomes eligible when expenses exceed 10% of income. Higher incomes must build up bills equaling higher percents of income. This will provide a baseline safety net against total impoverishment for someone stuck between Pool rules and poor or no coverage. Benefits
Current Pool rules allow hospitals and community health centers to provide any care deemed “medically necessary.” The new rules tighten that somewhat, by specifying a broad array of benefits tied to the MassHealth Standard benefit package. MassHealth Standard provides the most extensive benefits of any MassHealth program. The key impact will be on prescriptions. The regulations require Pool pharmacies to follow the MassHealth formulary and prescribing rules, such as prior approvals. The rules also continue the existing “critical access services” regulation. Hospitals may only provide hospital-level care, not outpatient clinic visits or non-urgent primary care. Those services may only be provided at community health centers (CHCs). An exception is made if there is no center within 5 miles of the hospital. Cost Sharing
The most radical change by far is the introduction of cost sharing, both deductibles and co-pays, for hospital care for patients 150%-200% FPL in Health Safety Net – Primary, what used to be Full Free Care.-Adapted from: A healthy blog- Brian Rosman of HCFA “New Lifeguard, New Pool”, 7/12/07 at http://blog.hcfama.org/?p=1093, A healthy blog- Brian Rosman “Another Pool Reg Gotcha” at http://blog.hcfama.org/?p=1095, The Boston Globe “Free Care May com at a cost to the poor; State Proposes copayments”, by Alice Dembnew, 7/13/07 at http://www.boston.com/news/local/massachusetts/articles/2007/07/13/free_care_may_come_at_a_cost_to_poor/; and MIRA Bulletin: July 24th, 2007 from MIRA.Deductibles
Echoing the $35/month premium charged in Commonwealth Care for members between 150%-200% FPL, the Pool will require a $35 per month deductible to be paid when a patient uses a hospital or hospital-licensed Community Health Center (CHC). Patients earning between 200 percent and 400 percent of the poverty level would face a larger deductible, based on their income. There are no deductibles collected when using an independent CHC or not using any services, but the $35/month continues to accrue.For example, imagine someone at 151% FPL ($15,325 for an individual) becoming eligible for the Pool in January. The person uses no services in January, visits an independent CHC in February, and uses no services in March, April and May. So far, no deductible payments are due. In June, the patient gets care at a hospital. The deductible, billed to the patient, is $210, which is the $35/month for the 6 months the patient has been in the Pool. If the patient used no hospital services again for a full year, until June of the following year, the deductible would be $420. No deductible can exceed $420.
The patient will be responsible for tracking and documenting the deductible if there is more than one family member or more than one hospital involved.
Editorial comment from Brian Rosman, Health Care for All “Healthy Blog”: We strongly object to the amount and form of these charges, particularly the accumulating deductibles, which feels more like a premium than a deductible (a “deductemium?” “preductible?”). The goal of the charge is not to encourage people to sign up for Commonwealth Care – the deductible only applies to people already ineligible for CommCare. The goal also can’t be to encourage use of CHCs for primary care, since hospitals are only covered for services that only a hospital can provide. Rather, the goal is to simply match the CommCare premium, for the sake of equity. However, the value of the Pool is far less than the value of CommCare, which is real insurance. A number of health centers, like in Lawrence and Fall River, rely on nearby hospitals for x-rays and other diagnostic tests. Their pool patients will have to pay the deductible and copay every time they are sent to the hospital for a test. We hope to work with the administration to clarify and improve the regulations as they go through the policy process.
Editorial comment from the MGH Community News: Additionally this has the potential to either interrupt continuity of care or cost patients to continue to receive care here or at one of our health centers. Not to mention that this is assuming that those affected even understand the rules before they seek care.
Copays
Copays are modeled on Commonwealth Care copays. Co-pays will apply to those between 100 and 200% FPL. They are set at the following: Outpatient/Community Health Center visit= $5; Inpatient Admission to Hospital=$50; Emergency Room Visit=$50 (waived if admitted); Pharmacy=$1or $3 There are no copayments or deductibles for children or for care at (independent?) community health centers, other than a $3 charge for each prescription filled. So in the example above, someone admitted to a hospital twice in a 12-month period would pay $520.Children are exempt from co-pays. The regulation does not exempt children from the deductibles, but we assume that was an oversight by the agency.
Hospital Reimbursement and Rationale
The state will no longer reimburse hospitals and community health centers for care they provide if the patients are eligible for insurance through the state Medicaid program, state-subsidized Commonwealth Care, or affordable coverage through their work. Unnamed hospital officials told the Boston Globe that they would not turn away patients needing urgent care, but that they probably would be more aggressive in billing those patients.The new provisions were required under the state law that mandates that all adults obtain insurance coverage this year, if the state deems it affordable for them. The state is drawing on funds previously used for free care to pay for insurance subsidies and is counting on weaning as many people as possible from free care.
The number of people using the pool already has dropped 20 percent this year compared with last year, according to state officials, in large part because 155,000 people now have insurance through the state's near-universal coverage initiative. But hundreds of thousands of patients are still using the pool.
The state allocated $605 million for free care this year, but the fiscal 2008 budget Governor Deval Patrick approved this month includes only $354 million for the pool's successor, the Health Safety Net Trust Fund.
"We did not want the trust fund to look more attractive to people than insurance," said Dr. JudyAnn Bigby, state secretary of Health and Human Services, as she explained the rules. Rather, she said, the rules are designed to make sure free care serves as a safety net for people without access to insurance, those whose insurance is inadequate, and those who face extraordinary medical expenses. The rules are subject to a public hearing, scheduled for Aug. 22, and may be revised before they are imposed on Oct. 1.
The proposals drew support from advocates and healthcare providers, but also concern that the new copayments would deter some people from seeking care and could leave hospitals with extra debt if patients get care but are unable to pay for it.
"We think the regulations are a great step forward and will ensure that most folks who can't find affordable coverage will maintain access to critical life-saving services," said John McDonough, executive director of the advocacy group Health Care for All . "But we are concerned that for an individual making between $15,000 and $20,000, there will be a new deductible that accumulates on a monthly basis whether or not they actually use any medical services. That means that someone could get services in January, then go back in December and face a bill of about $385 before they could get served."
Joe Kirkpatrick, vice president of the Massachusetts Hospital Association , said, "Patients should expect more rigorous collection and enforcement efforts" from hospitals if the new rules are imposed. Hospital officials also want the state to help medical facilities foot the bill, he said, if patients do not pay deductibles or if uninsured patients with access to insurance nonetheless seek emergency care at hospitals.
"We're not going to turn people away," said Ellen Murphy Meehan , a spokeswoman for the Alliance of Safety Net Hospitals . "But we believe there's a shared burden of responsibility."
There will be a hearing for the public to voice their opinions on the proposed changes on Wednesday, August 22nd at 9:30am at One Ashburton Place on the 21st floor.
7/07