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Tuesday, January 7, 2014

Iowa Becomes 7th State with a Republican Governor to Expand Medicaid

Dee Mahan

Earlier last month, the Centers for Medicare and Medicaid Services (CMS) gave Iowa approval to move forward with its Medicaid expansion, making Iowa the seventh state with a Republican governor to do so.

The result?

Starting January 2014, an estimated 150,000 uninsured Iowans can get health coverage through Medicaid. But as Iowa's expanded Medicaid program unfolds, some of its modifications to the Medicaid program need to be tracked closely to ensure that they don't impede access to health care for enrollees with very low incomes.

Iowa needed approval from CMS before moving forward with its Medicaid expansion because of its request to waive certain program requirements. The state filed a two-part waiver request with CMS outlining its intended plan - most of which was approved. The main thing CMS did not approve was the state's request to charge health insurance premiums to very low-income Medicaid enrollees - those with incomes between 50 and 100 percent of the federal poverty level (an annual income of between $9,765 and $19,530 for a family of three). Families USA supports CMS's decision to turn down this part of Iowa's proposal.

While that's good news, there are still some aspects of the program that bear watching.

Which of Iowa's Medicaid program modifications do advocates need to track? Pay attention to these four aspects of the program:

1. Iowa will still be charging premiums to some low-income Medicaid enrollees.

CMS approved Iowa's request to charge monthly premiums to individuals with incomes between 100 and 138 percent of poverty (an annual income of between $19,530 to $26,951 for a family of three). Premiums will be 2 percent of income. That's a departure from Medicaid law, which limits monthly premiums to individuals with incomes over 150 percent of poverty (an annual income of $29,295 for a family of three)

Though these monthly premiums won't go into effect until 2015, they can make it harder for people in Medicaid to keep coverage. Advocates should be watching to see how this affects enrollees' ability to stay in the program.

2. How private marketplace health insurance plans meet the needs of low-income Iowans

CMS also approved Iowa's request to cover Medicaid enrollees with incomes between 100 and 138 percent of poverty through the new state health insurance marketplace (as opposed to through traditional Medicaid). The state will buy insurance policies for Medicaid enrollees within this income bracket. This approach to Medicaid coverage is called “premium assistance” and sometimes referred to as “the private option.” It has not been used in Medicaid on a large-scale before.

Iowa is now the second state to use this approach to cover people in its Medicaid expansion - Arkansas was the first.

Because private marketplace plans are not accustomed to serving low-income individuals, advocates need to watch how this delivery system works.

3. How the details of Iowa's Medicaid's wellness program, which have yet to be defined, will affect residents

Iowa's program will include incentives for healthy behaviors, the details of which are still being worked out. The state needs to submit program protocols to CMS by March 31, 2014.

Advocates need to watch what's in those protocols. Whether these programs promote healthful behaviors depends on how they are structured.

For example, programs that base rewards on achieving certain health outcomes - like reaching a set weight-loss goal - can set enrollees up for failure and make it less likely that they will stick with the program. Programs that reward enrollees for participating in health-promoting activities, like attending weight-loss classes - are more likely to achieve good results.

4. How Iowa's decision not to provide non-emergency transportation to and from medical care will affect residents

For Medicaid enrollees with incomes between 100 and 138 percent of poverty who will be getting their coverage through private health plans, Iowa will not be providing non-emergency transportation to and from medical care (at least not in the program's first year). That's a required Medicaid benefit under the Affordable Care Act, but CMS has approved Iowa's request to waive this requirement. After one year, CMS will monitor how waiving this requirement affects beneficiaries' access to health care and decide whether or not to extend the waiver.

Letting the state bypass this requirement is particularly concerning given the structure of Iowa's wellness incentives. The state will waive monthly premiums only for enrollees who meet the wellness program requirements. By not covering non-emergency transportation, it could be harder for enrollees to get the care they need and achieve their wellness goals.


It's good to know that CMS is working closely with states to ensure that their modifications to Medicaid continue to serve the best interests of health care consumers. And while we may express concern for how Iowa is modifying some parts of its Medicaid expansion program, we applaud the state for its efforts to expand much-needed health coverage to 150,000 Iowans in 2014.