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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

STATE ELIGIBILITY POLICIES WHICH DISCRIMINATE AGAINST  THE DISABLED IN THE MEDICAID, MEDICAID WAIVER EXPANSION, CHIP, AND STATE-FUNDED HEALTH & PHARMACY ASSISTANCE PROGRAMS

By Thomas P. McCormack  [Draft # 8,  October 7, 2005]

[Nationally, Medicare (including Part D) excludes the disabled still in the 2 year waiting period and the Commodity Supplemental Food Program (CSFP) denies eligibility for at least $60/$70 monthly in food, toiletries, OTC first aid/pharmacy items and cleaning/laundry supplies to childless disabled persons under age 60.]  

Some state Medicaid, Medicaid waiver expansion, Child Health Insurance (CHIP), state-funded health assistance and state pharmacy assistance programs (SPAPs) have rules that deny eligibility, coverage, equal income levels or benefits to disabled and aged persons.

State Pharmacy Assistance Programs (SPAPs)

Many state pharmacy assistance programs(SPAPs)  for Medicare patients who are somewhat “too rich” for Medicaid deny eligibility or equal benefits to disabled persons under 65 and only cover persons over 65 or give them more benefits than the disabled..

State Prescription Assistance Programs State Prescription Assistance Programs

Which Exclude the Disabled Under Age 65 Which Cover the Disabled Under Age 65

Florida                                                                Connecticut

Indiana                                                                Delaware*(caps dis benefit but not aged)

Kansas  (age 67)                                                 Illinois*(lesser formlry for dis than aged)

South Carolina                                                    Maryland*(some dis in 2yr wait exclud.)

Michigan (whole program ends 1/1/06)              Massachusetts

Wisconsin                                                           New Jersey

Missouri                                                              Vermont

Nevada (age 62)                                                  Wyoming *(dis in 2 yr wait excluded)

New York                                                            

North Carolina                                                  

Pennsylvania

Rhode Island *(covers only those disabled over 55, who get lesser benefits than aged)

* Gives lesser SPAP benefits/coverage to disabled under age 65 than to aged over 65.

    

States Excluding or Using Lower Income  Levels For  Disabled (& Often Aged) on Medicare in Medicaid & CHIP Section 1115 Waiver Income Eligibility Expansions

Arizona---waiver to cover parents up to 200% FPL appears to exclude aged and disabled on Medicare, who must meet lower 100% level to get Medicaid.

Hawaii---gives Medicaid to all uninsured adults under 200% except aged and disabled (whether on Medicare or not) who must meet lower 100% level to get Medicaid.

Illinois---“Pharmacy Plus” waiver gives full Medicaid drug coverage to aged but not disabled under 200%; those disabled under 200% get only narrower formulary of state-funded drug coverage. Disabled must be under lower 100% level to get full Medicaid services, including full drug coverage.

Indiana---state keeps in force an even stricter-than-SSI “209(b)” Medicaid disability rule that one be fatally or incurably incapacitated to get Medicaid. 

Maryland---offers drugs, but not other Medicaid benefits to anyone (aged, disabled or not) under about $890/mo. @ $2/$7 co-pays; state has 2nd SPAP to offer Medicaid drugs to Medicare patients only under 175%  (but with a hefty 65%-of-Medicaid-price co-insurance), thus excluding those disabled in 2 yr. Medicare waiting period); to get Medicaid drug & other benefits, aged & disabled must be under $579 SSI income level.

Massachusetts---pays $14.43 higher SSI state supplement to the aged than it pays to the disabled.

Minnesota---gives Medicaid to all uninsured, childless adults under 175% except Medicare eligibles, who must meet lower 100% level to get Medicaid

Nevada---gives Medicaid to aged over age 60 using $36.40 higher-than-SSI State Supplement income level, but disabled must meet lower, un-supplemented  $579 basic SSI monthly income level to get Medicaid.

New Jersey---offers waivered Medicaid/CHIP to all parents under 133% but childless Medicare eligibles must meet lower 100% aged/disabled level to get Medicaid

New Mexico---gives (watered-down) Medicaid to all adults under 200% except  Medicare eligibles, who must meet lower SSI income level to get Medicaid.

New York---gives Medicaid to all uninsured childless adults under 100% except Medicare eligibles who must meet lower $667 SSI/SSP level to get Medicaid

Oregon---gives Medicaid to some aged and disabled adults under 100% except Medicare eligibles, who must meet lower $579 SSI income level to get Medicaid

Utah---gives watered-down Medicaid (no inpt hosp care) with high co-pays ($50 prem; $10 gen drug copay; 25% brand drug co-pay) to all uninsured adults under 150% except Medicare eligibles who must meet lower 100% level to get (full) Medicaid

Vermont---gives Medicaid to all uninsured adults under 175% , but Medicare eligibles over 100% get only partial Medicaid drug coverage only and not other Medicaid services

States Excluding or Using Lower Income Levels For Disabled (& Aged) on Medicare In State-Only-Funded Health Care Programs

Alaska---has state-funded “Senior Assistance Program” benefit (either $120 monthly, or up to $1600 a year in drugs) to aged under 135% , but not to the  disabled; these benefits are given to these aged whether or not they can also get the regular aged/disabled State Supplementary Payment (SSP) to SSI, which has an income level of over $900 monthly (and only actual receipt of the regular SSP or SSI confers Medicaid coverage too).  

Arizona—offers state-funded “Premium Assistance” medical coverage, including prescriptions, to anyone under 250% (and under 400% to those with state-defined chronic conditions) with small premiums and co-pays, except for Medicare eligibles; closed to new applicants as of 6/02, but prior recipients are still grandfathered-in..        

Colorado---offers 100% state-funded “Medicaid” to those over 60 using $37 higher-than-SSI  SSP level, but uses only lower, regular $579 SSI level for disabled under 60.

District of Columbia---offers city-funded clinic and HMO care to everyone under 200% except childless Medicare eligibles who must meet lower 100% level to get Medicaid.

New York----the state-subsidized Healthy NY health insurance plan (premium for a NY City single was about $205 in 2001), for those under 250% excludes those working under 20 hours weekly and Medicare patients and caps Rx coverage at only $3,000 yearly.

Pennsylvania---offers state-funded health insurance (but with no drug coverage) to everyone under 200% except Medicare eligibles who must meet lower 100% level to get Medicaid; yet new enrollments are now suspended due to funding shortage.

Washington---offers state-funded health insurance to some persons under 200% except Medicare eligibles who must meet lower SSI or TANF income levels to get Medicaid. State funding shortages often limit enrollment and even some legal aliens are still barred. 

    

States With State-Funded Health Insurance Risk Pools Which Deny Enrollment to Disabled (& Aged) Medicare Eligibles or Deny Them Fair Premium Discounts

Twenty nine states sponsor state health insurance risk pools, which offer health insurance for those who cannot get insurance at all, at reasonable rates or without prohibitive preexisting condition limitations. Most, but not all, ban enrollment of Medicare eligibles. Of those that do allow them, only a few offer premium discounts because Medicare is primary payer. (And a few states that do cover Medicare eligibles give them only a standard Medigap plan [without meaningful drug coverage] rather than full secondary coverage in the risk pool.) See Comprehensive Health Insurance For High-Risk Individuals, 2005  (Communicating For Agriculture at http://www.selfemployedcountry.org, [218] 739-3241); contact Natl Assoc of State Comprehensive Insur Plans (NASCHIP) lhp@lahealthplan.org (225) 926-6245; and see “Insuring the Uninsurable: An Overview of State High Risk Insurance Pools” (08/ 01) at www.cmwf.org .

Maryland just passed legislation and regulations for its own health insurance high risk pool. In many states Medicare patients---and especially the more vulnerable disabled ones—are denied enrollment and/or the fair premium discount they deserve since they bring Medicare to the table as their primary payer.

State Health Insurance Risk Pools: Access, Characteristics and Typical Premiums

State  Char.         Typical monthly premium  (2001)

AL   1, 6, 9                 $206

AK  2, 3, 4                   445

AR  1, 6, 7

CA  1, 6, 10                  319

CO  5, 6, 8                    229

CT  2, 6, 7, 8

FL   2, 3, 4, 6, 7, 10

IL    2, 3, 6, 10              307

IN    2                            225

IA    2, 3, 6                    425

KS   1, 6                        371

KY   5, 6, 7

LA   1, 6, 7

MN  2, 3, 6                    411

MS   5, 6, 7, 11

MO  5, 6, 7

MT   2, 3, 4, 6                233

NE   2, 6, 7

NM  2, 6, 7                    237

ND   2, 3, 4, 6                224

OK   1, 6                        218

OR   2, 6, 8                    313

SC    5, 6                        280

TN   2, 6, 8                     0-155

TX   5, 6                        230

UT   5, 6                         238

WA  2, 3, 4, 6, 8            298

WI    2, 3, 6, 8               186

WY   2, 3, 4 , 6              239

Premium shown is the 1999 or 2000 rate for a 35 year-old male non-smoker in largest city for plan with lowest deductible and least managed care limits, not reflecting any low income or Medicare discounts.

1.     Bans Medicare eligibles

2.     Allows Medicare eligibles

3.     Gives Medicare eligibles discount when the risk pool is the secondary coverage

4.     May only offer Medicare eligibles one of the federally defined (options A through J) “Medigap” plans

5.     Policy on Medicare eligibles unknown.

6.     May have statute/rule banning use of public funds to pay premium.

7.     Call state insurance comr. & risk pool staff for premium by sex, age, city, plan type & deductible

8.     Premium reduction for those considered “poor” under state guidelines (CO under $30,000; CT under 200% poverty; NM 200%; OR 170%; TN 400%; WA 300%;  WI $24,000)

9.     Only for federal HIPAA portability eligibles

10.   Enrollment either closed continually (FL, IL) or has waiting list (CA).

11. Bans those already on Medicare from joining pool, but lets them stay in pool if they get it afterwards.