Dear Secretary Becerra:
Thank you for the opportunity to submit comments on the MassHealth 1115 Medicaid Demonstration Amendment Request.
The undersigned organizations represent millions of individuals facing serious, acute and chronic health conditions. We have a unique perspective on what individuals and families need to prevent disease, cure illness and manage chronic health conditions. The diversity of our organizations and the populations we serve enable us to draw upon a wealth of knowledge and expertise that is an invaluable resource regarding any decisions affecting the Medicaid program and the people that it serves. We urge the Centers for Medicare and Medicaid Services (CMS) to make the best use of the recommendations, knowledge, and experience our organizations offer here.
Our organizations are committed to ensuring that Massachusetts’ Medicaid program provides quality and affordable healthcare coverage. Our organizations appreciate the emphasis on health equity in this waiver and support the inclusion of retroactive eligibility for all enrollees, continuous eligibility for adults, pre-release coverage for justice-involved populations, and expanded financial assistance for marketplace coverage. Our organizations urge CMS to approve these requests and offer the following comments on the MassHealth 1115 Demonstration Amendment Request:
Retroactive Coverage
Our organizations support the proposal to reinstate retroactive coverage for all demonstration populations. Retroactive coverage is an important policy to advance health equity and a safety net for low-income families. It is common that individuals are unaware they are eligible for Medicaid until a medical event or diagnosis occurs. Retroactive eligibility allows patients who have been diagnosed with a serious illness to begin treatment without being burdened by medical debt prior to their official eligibility determination, providing crucial financial protections to newly enrolled beneficiaries.
Retroactive coverage is also important for current Medicaid enrollees. Medicaid paperwork can be burdensome and often confusing. A Medicaid enrollee may not have understood or received a notice of Medicaid renewal and only discovered the coverage lapse when picking up a prescription or going to see their doctor. In Indiana, Medicaid recipients were responsible for an average of $1,561 in medical costs with the elimination of retroactive eligibility. Medical debt disproportionately affects families of color in the US and is a predictor of other social drivers of health such as homelessness. Retroactive coverage prevents Medicaid enrollees from facing substantial costs at their doctor’s office or pharmacy and subsequent delays in care.
Given the importance of this policy change, CMS should work with Massachusetts to reinstate retroactive coverage sooner than 2025. Many patients are facing gaps in coverage as a result of procedural disenrollments during the Medicaid unwinding process. The state should work with CMS to reinstate retroactive coverage as soon as possible to protect enrollees from the financial and health risks of a gap in coverage.
Continuous Eligibility
Our organizations support the proposal to provide 12-month continuous eligibility for all adults, as well as 24-month continuous eligibility for seniors experiencing homelessness. Continuous eligibility promotes health equity and increases continuity of coverage.
Continuous eligibility protects patients and families from gaps in care. Research has shown that individuals with disruptions in coverage during a year are more likely to delay care, receive less preventive care, refill prescriptions less often, and have more emergency department visits. Gaps in Medicaid coverage have also been shown to increase hospitalizations and negative health outcomes for ambulatory care-sensitive conditions like respiratory and heart disease. Our organizations support continuous eligibility as a method to reduce these negative health outcomes for patients.
This policy will also reduce churn within the program and its administrative burden on Medicaid offices. Research shows that 40% of Medicaid enrollees who lose coverage are re-enrolled in the program within a year. One study estimated that the administrative cost of churn was between $400 and $600 per person in the Medicaid program. Continuous eligibility eases the administrative burden that these changes in enrollment status place on patients and the program.
As discussed above, because this policy would be especially impactful during the Medicaid unwinding process, our organizations encourage CMS to work with Massachusetts to move up the implementation date for this policy from January 2025.
Pre-Release Services for Justice-Involved Populations
Our organizations support the proposed coverage of specific services for incarcerated individuals who are otherwise eligible for Medicaid for up to 90 days prior to release. This is consistent with the goals of Medicaid and will be an important step in improving the continuity of care. This proposal will help these high-risk populations access critical supports needed to treat physical and behavioral health conditions. For example, studies in Washington and Florida reported that people with severe mental illness and Medicaid coverage at the time of their release were more likely to access community mental health services and had fewer detentions and stayed out of jail longer than those without coverage. We urge CMS to approve this request.
Eligibility Increase for Marketplace Subsidies
Our organizations support the expansion of eligibility for ConnectorCare subsidies from 300% to 500% FPL. This waiver would support subsidies for premiums and cost-sharing for individuals determined eligible for up to 100 days while they select, pay, and enroll into a marketplace plan. Research consistently shows that higher cost-sharing is associated with decreased use of preventive services and medical care among low-income populations. Expanding eligibility for the subsidy program would ease the transition to the Marketplace and mitigate gaps in coverage. In addition, CMS should ensure that the eligibility change is included in the demonstration’s evaluation, to see the effect of out-of-pocket costs on coverage transitions.
Conclusion
Our organizations support Massachusetts’ efforts to improve equitable access to quality and affordable health coverage. We urge CMS to approve the state’s request to reinstate retroactive coverage, expand continuous eligibility, improve access to care for the justice-involved population, and increase eligibility for marketplace subsidies. Thank you for the opportunity to provide comments.