WV--West Virginians for Affordable Health Care

May 4, 2009 Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-2232-P and CMS-2244P PO Box 8016 Baltimore, Maryland 212244-8016 Dear CMS, On behalf of West Virginians for Affordable Health Care (WVAHC), I am submitting the following comments on State Flexibility for Medicaid Benefit Packages Proposed Rule, 42 Federal Register 9714. WVAHC is a state-wide, non-profit -- 501(c)4 -- public interest organization working on systematic health care reform efforts (see www.wvahc.org). WVAHC represents the interest of health care consumers, including low-income consumers. The experience in West Virginia with Medicaid benchmark benefit plans has not been positive. On May 3, 2006, CMS approved the Mountain Health Choices (MHC) plan that established a two-tiered benefit package for children and parents in West Virginia: a basic plan and an enhanced plan. The basic plan, which is the default plan, reduced benefits from traditional Medicaid in a number of areas, including limits on prescription drugs and mental health services. These benchmark plans were approved under the Secretary-approved coverage option with no meaningful public participation. The publicly stated goal of the Mountain Health Choices program was to improve the health status of children and parents enrolled in the state’s Medicaid program. However, as of December 2008, only 12.2 percent of children and 9.6 percent of adults were enrolled in the enhanced program. Given the low enrollment in the enhanced program, it is reasonable to ask: How is West Virginia improving the health status of Medicaid children and parents, when 88 percent of the participants are receiving a reduced benefit package? Additionally, since there was no baseline health status data collected on those who selected the enhanced plan (LDL levels, BMI levels, blood pressure levels, smokers or non-smoker, etc.), it is impossible to determine whether the health status of those who selected the enhanced plan has improved. Additionally, since selection into the enhanced program is parental or self-selecting rather than based on risk factors, it is possible – indeed likely – that there is positive selection in the enhanced program. West Virginia may actually be offering nutritional education to the non-obese population, while denying nutritional education to obese children and adults. Despite repeated attempts by WVAHC, West Virginia Department of Health and Human Resources (WVDHHR) has refused to examine the health status of those selecting the enhanced plan to determine whether positive selection is occurring. In order to prevent other states from adopting West Virginia’s mistakes with benchmark benefit packages, WVAHC is making the following recommendations for changes in the final rule. ? §440.335 should be modified to either exclude the Secretary-approved coverage option, or at a minimum, require traditional Medicaid benefits, including optional benefits that have previously been covered, be the default option where the benchmark benefits includes a tiered package. CMS should not allow a state to adopt benchmark plans that results in 88 percent of participants receiving a reduced benefit package. This is not good public policy, and should not be permitted by CMS. ? §440.315 should be modified to exempt parents eligible under section 1931 of the Social Security Act rather than exempting “individuals who qualify for Medicaid solely on the basis on qualification under the State’s TANF rules,” since this category of individuals no longer exists. Since 1996, eligibility for Medicaid has been delinked from cash assistance programs, and therefore, the exemption applies to a null group. Applying the exemption to parents who are eligible under section 1931 would achieve the statutory intent of Congress, and would have protected West Virginia parents from the reduction of benefits that they have received under the basic plan in Mountain Health Choices. ? §440.315(f) should include a definition of medically frail or special medical needs individuals. These individuals should be exempt from participating in benchmark plans. This recommendation is similar to the findings of West Virginia University Health Policy Institute and Mathematica Policy Research evaluation of Mountain Health Choices (MHC): “Consideration should be given to examining what population groups are best suited for inclusion in a program such as MHC. For example, the program may not be well suited for people with serious mental health problems.” Medically frail and special medical needs individuals are not well suited for inclusion in a benchmark plan that reduces benefits, and therefore, should also be excluded from participating in these plans. In addition to these three recommendations, WVAHC is submitting two additional recommendations that were not specifically addressed by the rule. These two additional recommendations warrant further CMS guidance, and include the following: ? According to the evaluation of the Mountain Health Choices program by WVU Health Policy Research Institute and Mathematica, one of the primary reasons for low enrollment in the enhanced program is the lack of education and public outreach to beneficiaries. If CMS is going to allow beneficiaries to enroll in benchmark plans on a voluntary basis, then CMS should require, at a minimum, that information provided beneficiaries be in the beneficiary’s spoken language and at an appropriate reading level. Information should clearly inform beneficiaries of: a) The increase in benefits or the reduction in benefits as a result of their decision to enroll in a benchmark plan, and b) Any appeal rights that they may have as a result of choosing a benchmark plan. ? Finally, as noted above, the benchmark plans in Mountain Health Choices were submitted to CMS without meaningful public participation. Prior to submission of the draft plan to CMS, WVDHHR did not publish the draft state plan amendment in the State Register, nor provide the public with a thirty day comment period, nor hold any public hearings on the draft plan. (The state plan amendment was submitted to the West Virginia Medicaid Advisory Council, but there was no other public participation.) CMS does require public participation in waivers, but allows state plan amendments to be submitted with no public participation. CMS should modify the proposed final rule to require, at a minimum, notice and a thirty day comment period, and a public hearing to explain the proposed benchmark benefit plan(s) and an opportunity for citizens to make comments on proposed benchmark plan(s) prior to submission to CMS. Thank you for consideration of these comments. Should you have any questions about our concerns and recommendations, please don’t hesitate to contact me. Sincerely, Perry Bryant, Executive Director West Virginians for Affordable Health Care perrybryant@suddenlink.net 1544 Lee Street, East Charleston, West Virginia 25311 304.344.1673 (Voice) 304.344.1242 (Fax)