There is much variation in how states manage Medicaid benefits for the “Medically frail,” UMass Medical School expert finds

June 16, 2017

Whether the nation’s sickest and most vulnerable people receive full Medicaid benefits hinges on what states they live in, notes Sherry Campanelli, MPA, an expert in disability evaluation at UMass Medical School.

While a few states, like Massachusetts, require individuals to declare themselves “medically frail” before extending the full slate of health coverage benefits, others, like Kentucky, employ a battery of complicated assessments and tests, notes Campanelli, manager of program compliance and appeals at the Disability Evaluation Services unit of Commonwealth Medicine, a division of UMass Medical School.

The “medically frail” include individuals with serious medical and physical disabilities, children with emotional problems or in foster care, and those with chronic substance abuse problems, among others.

Campanelli has extensively researched the criteria used by states across the country to determine whether people are medically frail and therefore eligible for full Medicaid benefits, with those findings presented June 25 at the AcademyHealth Research Meeting.

“It is interesting to examine some of the different ways that states provide access to full state plan Medicaid for their medically frail population,” she notes.

The discrepancy stems from the 2010 passage of the Affordable Care Act (ACA).

States who agreed to accept federal money under Obamacare to expand their Medicaid programs were required to form “alternative benefit plans” for the new enrollees.

Most states agreed to offer the same level of Medicaid benefits offered in their core health to the millions covered by the expansion of the federal health care program for the poor and disabled under Obamacare.

But the alternative plans rolled out by Kentucky and several other states under Medicaid expansion were less generous than the benefits offered under their traditional Medicaid programs.

One big exception has been the “medically frail,” who have the option under federal health regulations to tap into more extensive benefits provided by traditional state Medicaid programs. They don’t have to enroll in the new, alternative plans if they are inferior.

The states that offer less extensive benefits under their Medicaid expansion plans, in turn, are required to come up with their own systems for determining whether individuals are medically frail or not, and thus qualify for full Medicaid benefits.

But the requirements vary widely from state to state.

Kentucky conducts a health risks assessment, reviews claims data, assigns a health risk score and analyzes that using health insurance underwriting guidelines in order to make a determination, according to Campanelli.

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