LINCOLN — The two-tier Medicaid system that officials are proposing as a way to cover more low-income Nebraskans would be unique to the state.
The Heritage Health Adult system would include work, wellness and personal responsibility requirements, many of which have been tried by other states. However, the combination of requirements and the penalties for failing to meet requirements would be new.
As outlined by state officials, people would not get dental, vision and over-the-counter medication coverage if they fall short on any of the requirements. But they could still keep physical, medical and prescription drug coverage. Reviews would be done every six months to determine compliance.
“This is a very Nebraska-specific program that we have put forth,” Matthew Van Patton, the state Medicaid director, told lawmakers recently. “Nobody under this model loses benefits.”
To implement the proposed system, Nebraska will have to get federal approval to waive traditional Medicaid rules.
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Robin Rudowitz, vice president of the Kaiser Family Foundation, which tracks such waivers, said the Nebraska approach would be different from waivers that have been implemented around the country. But it would share some features with waiver programs tried in other states, including Indiana and Iowa.
The most-common shared feature would be Nebraska’s plan to end retroactive eligibility for most Medicaid patients. The change would mean coverage starts in the month a person applies for Medicaid. Under current regulations, coverage goes back three months before the application date.
Here are some lessons that can be drawn from other states’ experiences:
No state has work requirements in effect for Medicaid recipients. Nearly 20 states are in various stages of trying to establish work requirements for Medicaid recipients, with encouragement from the Trump administration. Nine states are in the process of trying to get federal approval.
In three states, the requirements were blocked by courts, which have ruled that they undermine Medicaid’s mission of providing health care for the needy.
Six states have federal approval but have not implemented the requirements. Two of the six, Arizona and Indiana, voluntarily suspended implementation efforts. Arizona officials cited the court decisions in other state. Indiana’s requirements are facing a legal challenge.
Other states would suspend benefits or cut eligibility for falling short on work requirements. All other states seeking to implement work requirements have proposed suspending benefits or dropping people from Medicaid if they fail to comply with the requirements. The states vary in how long the suspension or loss of eligibility would last and how people could regain benefits.
Nebraska is proposing to limit, not suspend, benefits. State officials have touted that difference. Van Patton called it a “mark of distinction” among other states.
But the requirements look similar otherwise. All states, including Nebraska, would accept a variety of activities as meeting the work requirement, such as education, internships, substance abuse treatment, job searches and volunteer work.
All would exempt certain groups from the requirements. Commonly exempt are pregnant women, people with serious mental illnesses and family caregivers.
Wellness incentives have had limited success in other states. A handful of other states, including Iowa, have incorporated some wellness incentives and penalties into their Medicaid waivers, as Nebraska is proposing to do.
Nebraska would provide additional benefits to people who meet all of the wellness requirements — taking a health risk screening and an assessment of social determinants of health, filling prescriptions, having lab work done, going in for an annual doctor visit and choosing a primary care provider.
But only limited numbers of people have completed wellness activities in other states.
Michigan offers a $50 gift card to Medicaid patients below the poverty line or a reduction in future premiums to those above poverty who complete a health risk assessment. A 2017 Kaiser study found that just 16% had done the assessment.
In Iowa, Medicaid patients can avoid paying small monthly premiums by getting a yearly exam and doing a health risk assessment. But state reports show that fewer than one in four complete both requirements.
Ending retroactive eligibility would increase costs for patients and providers. Eight states, including Iowa, have won federal approval to end retroactive eligibility, according to the Kaiser waiver tracker. The courts have put the change on hold in three of those states.
Von Patton said Nebraska is proposing the change to make Medicaid more like commercial insurance and to encourage people to sign up before they get sick. The change would affect people newly eligible for Medicaid because of expansion and people previously eligible for Medicaid, with some exemptions.
Critics said that ending retroactive eligibility hurts health care providers as well as patients. Retroactive eligibility means that doctors and hospitals get paid for care provided to people who qualify for Medicaid but have not yet enrolled, while patients are not faced with medical debt.
The change can save money for state Medicaid programs. When Iowa launched its change, officials estimated a savings of more than $36 million a year from ending retroactive eligibility for up to 40,000 people.
No other state has the same system of six-month benefit reviews. Nebraska appears to be alone in proposing reviews every six months to determine whether patients will get the basic tier of benefits or qualify for the premium tier, which includes dental, vision and over-the-counter medications.
Rudowitz said she doesn’t know of another state with such a requirement.
Nebraska officials originally wanted to determine eligibility for Medicaid every six months, not just review a patient’s benefit tier. But federal law requires annual determinations. The state backed away from the more frequent eligibility determinations after talking with federal officials.
Now, Van Patton said, the state will stick with annual eligibility determinations, with periodic checks to verify that people still qualify for Medicaid. In addition, there will be reviews every six months to see whether patients are meeting the requirements for the premium benefits.
He told lawmakers that Nebraska’s approach would lead to better and more cost-effective outcomes, while avoiding potential penalties for enrolling people who do not qualify for Medicaid.
“This is our best hope for bending the cost curve to build a sustainable program,” he said.
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Rain clouds and a bit of a rainbow roll over the Millard, Nebraska, sky on Aug. 16, 2016.
The sun sets behind a center pivot located north of Red Cloud, Nebraska, on Thursday, July 27, 2006.
Storm clouds hide the sun as it sets over Nebraska's Sand Hills on July 7, 2009, near Thedord, Nebraska.
A summer storm passes north of Rose, Nebraska, on Sunday, June 10, 2007.
A rainbow forms over U.S. Highway 12, just east of Valentine, Nebraska, as storms roll over the area on July 25, 2017.
The sun sets behind an approaching storm as a car heads west on U.S. Highway 34 near Union, Nebraska, on April 24, 2016.
Icicles form on vines in downtown Omaha on Feb. 24, 2017.
Railroad tracks are illuminated by the setting sun on May 3, 2017, east of Scottsbluff, Nebraska.
The sun sets behind Chimney Rock on May 3, 2017.
Members of the Boats, Bikes, Boots & Brews group head to shore as the sun sets after an evening out on Lake Zorinsky on April 22, 2015.
Icicles hang from the horse carriage parking sign in the Old Market on Jan. 15, 2017.
Wheat, ready for the combine, is silhouetted by the setting sun as the wheat harvest on the Lagler farm near Grant, Nebraska, was in full swing on July 7, 2005.
A layer of fog covers the Missouri River near the Bob Kerrey Pedestrian Bridge on Feb. 5, 2015.
A setting sun creates a pink haze on a windmill and the Sand Hills southwest of Rushville, Nebraska, on Sept. 22, 2007.
Pigeons scatter at sunset as the St. John's steeple is silhouetted against the Woodmen tower in downtown Omaha on Oct. 3, 2014.
The sun bursts behind the clouds over the North Platte River east of Bridgeport, Nebraska, on July 26, 2006.
Steve Jobman, a farmer south of Minatare, Nebraska, cuts alfalfa after sunset on June 2, 2004.
Wheat waves in the wind in a field west of Dalton, Nebraska, on July 18, 2001.
The moon rises over the northern cross of the St. Cecilia Cathedral in Omaha on Feb. 10, 2017. On this night, there was a full moon, a lunar eclipse and comet 45P passed by the earth.
As the wind speed picks up, a woman holds onto her hood while crossing 16th Street along Dodge Street in Omaha on Feb. 24, 2017.
From left: Melody Borcherding, Kseniya Burgoon and Michael Beltz scoop out a vehicle on Jan. 23, 2018, in Norfolk.
Jeff Bachman harvests soybeans and prepares to transfer them as the sun sets on a field near Ayr, Nebraska, on Oct. 19, 2008.
As the sun sets, sandhill cranes arrive to roost in the Platte River at the Rowe Sanctuary & Iain Nicholson Audubon Center south of Gibbon, Nebraska, on March 12, 2008.
A pair of sandhill cranes pass in front of the moon shortly after sunrise at the Iain Nicolson Audubon Center at Rowe Sanctuary near Gibbon, Nebraska, on March 13, 2012. Sandhill cranes, which mate for life, can live between 20 and 40 years.
A windmill is dwarfed by storm clouds near Crawford, Nebraska, on May 3, 2017.
An early November storm system rolls through the Great Plains, but Omaha only receives rain, which collected on freshly-fallen leaves on Nov. 11, 2015.
Cattle head up to a well to get a drink at the end of the day near Sparks, Nebraska, on Aug. 21, 2015. Smoke from the wildfires in the western states created a haze.
The moon rises above the corn as farmers harvest the last of their fields in eastern Nebraska and western Iowa on Nov. 5, 2014.
Two riders help round up part of the 750 head of cattle branded at the Lute Family Ranch, located south of Hyannis, Nebraska, on May 12, 2005. Mick Knott, who runs the ranch, owns about half the cattle, and the Lute Foundation owns the rest. The work started about dawn and finished about noon.
The rising sun illuminates a tree and a windmill in a snow-covered field located on U.S. Highway 20 between Rushville and Chadron, Nebraska, on March 1, 2017.
The College Home Run Derby was held at TD Ameritrade Park and was highlighted by The World-Herald's annual Independence Day fireworks display on July 2, 2015.
Fog rises from the Missouri River and covers the Bob Kerrey Pedestrian Bridge on Jan. 5, 2010.
The weekend's perfect weather colored the clouds at sunset south of Wymore, Nebraska, on Oct. 23, 2004.
Deer chill out at Chalco Hills Recreation Area on Feb. 22, 2018.
A leaf is covered in a dusting of snow near 138th and Hickory Streets on Dec. 18, 2014, in Millard.
A runner emerges from the edge of the rising sun on Sept. 11, 2015, at Zorinsky Lake Park and Recreation Area in Omaha.
Nearly 45 minutes after sunset, an orange and blue glow is seen setting behind the Omaha skyline flanked between trees in Council Bluffs on Jan. 11, 2018.
Rain drops collect on a flower following early showers on May 10, 2017, in Millard.
The promise of rain is fleeting for the seven windmills on the Watson Ranch north of Scottsbluff, Nebraska, on U.S. 71 on May 16, 2004.
A crescent moon sets behind the UNO bell tower on Nov. 6, 2013.
Ralph Remmert is depicted in the mural "Fertile Ground" near 13th and Mike Fahey Streets in north downtown Omaha on June 19, 2017.
Ralph Kohler, 94, keeps his eyes to the sky for ducks and geese as the sun rises over his hunting pond east of Tekamah, Nebraska, on Nov. 30, 2011. Kohler has been a professional guide for most of his life, and he is preparing for the spring season.
The sun rises over St. Paul Lutheran Church, located three miles north of Republican City, Nebraska, in March of 2004.
Geese are silhouetted in the color and clouds as the sun sets at Zorinsky Lake on Feb. 21, 2016.
The sun rises on Chimney Rock on Wednesday, Feb. 19, 2014, near McGrew, Nebraska.
Cranes walk through the shallow water of the Platte River shortly before sunset near The Crane Trust, which is close to Wood River, Nebraska, on March 13, 2012. The river provides cranes with a safe place from predators for rest at night.
A bespangled vest awaits a rider during Nebraska's Big Rodeo on July 25, 2013, in Burwell, Nebraska.
Horses stand in the snow on Feb. 22, 2018.
Residents of the Nebraska Panhandle enjoyed unseasonably mild temperatures and cloud cover on Aug. 12, 2004.
Members of the Professional Rodeo Cowboys Association hold their hats as 2013 Miss Burwell Rodeo Olivia Hunsperger passes by during the opening ceremonies on July 27, 2013, in Burwell, Nebraska. "This may be a small town, but it's got a big rodeo, and it's got a really big heart," Hunsperger said.
A break in the clouds highlights downtown Omaha as seen from Lewis Central High School in Council Bluffs, as severe storms passed through the Omaha Metro area on June 5, 2014.
John Wanief waits for the bus in a shelter at 120th Street and West Center Road as cold rain pours down in Millard on Nov. 11, 2015.
Flocks of waterfowl fill the sky as the sun rises over Ponca, Nebraska, on March 3, 2018.
A red tail hawk perches on a light stanchion backed by the moon and overlooking the property near the Indian Creek development in Omaha on Feb. 27, 2018.
A woman walks with two dogs in Memorial Park near Dodge Street as many sledders go down the hill in Omaha, Nebraska, on Feb. 2, 2016. MATT MILLER/THE WORLD-HERALD
The sun sets over Sidney, Nebraska, on June 2, 2015.
The rising sun shines on a snow-covered hill located north of Chadron, Nebraska, on March 1, 2017.
Storm clouds are illuminated by the setting sun as people exit a football camp in Lincoln on Friday, June 16, 2017.
Sharon Vencil walks her dogs, Blackie and Whitie, along the Field Club Trail on March 6, 2018, in Omaha.
The morning sun burns off a layer of fog just north of the Chimney Rock.
The sun rises behind one of seven wind generators as a windmill pumps water for cattle just northwest of Kimball, Nebraska, on Sept. 17, 2002.
A slightly less than full moon known as a waning gibbous is seen near the colorful Bob Kerrey Pedestrian Bridge on June 22, 2016.
A combine fills a truck with corn during harvest near Wahoo, Nebraska, on Oct. 22, 2015.