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By Rose Hoban
Since the beginning of March, more than a half-million North Carolinians have lost their jobs. And in a system where many workers receive health insurance through their employers, most of those people lost their access to health care too.
But most adults, even if they’re jobless and now broke, can’t qualify for Medicaid.
The waiters and bartenders, the hairdressers and the retail clerks, the hotel clerks and cleaning personnel, most of them won’t be eligible either.
“If you’re a 40-year-old man who’s just lost his job, you don’t have children, you’re not eligible for Medicaid,” said Gina Upchurch, head of Durham’s Senior PharmAssist and an advocate for increasing insurance coverage.
In short, young childless adults can’t receive Medicaid unless they’re permanently disabled or blind. Pregnant women get care up until birth and for three months following.
Under state Medicaid rules, children who have parents earning less than 200 percent of the federal poverty level (about $43,400 for a family of three) are eligible for care. For families earning only about $8,000 for a family of three, sometimes the parents can qualify for coverage too.
Even under those strict rules, consulting firm Health Management Associates estimates between 273,000 and 568,000 new beneficiaries will end up on the Medicaid rolls in North Carolina.
“It’s mostly going to be children,” said Dave Richard, North Carolina’s head of Medicaid.
There’s an adjustment to the limited eligibility, though. As the scope of the COVID crisis became apparent, North Carolina Health and Human Services Secretary Mandy Cohen had her department pull together a quick application to federal regulators to temporarily waive some of the state’s Medicaid income restrictions.
On March 27, North Carolina asked the federal Centers for Medicare and Medicaid Services for an emergency 1115 waiver to cover everyone who earns less than 200 percent of the federal poverty level for care related to COVID-19.
“It is clear the state requires additional federal flexibility and support that is available only through waivers under Section 1115,” Cohen wrote in a letter sent to CMS administrators.
The request, modeled on disaster relief requests after the Sept. 11 terrorist attacks and Hurricane Katrina, allows North Carolina to approve coverage for people who would otherwise be ineligible. This means they can seek care for “disaster-related costs” that would otherwise have gone unpaid.
Cohen letter to CMS administrators – March 27, 2020 (PDF)
Last week, North Carolina House Speaker Tim Moore (R-Kings Mountain) expressed support for the move, which would require legislators to give it the thumbs up.
That hasn’t happened yet. Lawmakers return to Raleigh on April 28 to take up that issue, along with other COVID-19-related policy and funding issues.
The application also asks federal regulators to approve a laundry list of items that include funds for temporary shelters for homeless people living in hot spots, extra dollars for behavioral health providers, and additional funds for food for eligible people.
North Carolina Institute of Medicine head Adam Zolotor pointed out that some of these flexibilities and the increase in state rolls wouldn’t be necessary if the state had expanded Medicaid because many of the low-income unemployed would be already covered.
And under Medicaid expansion, the state would only have been on the hook for 10 cents out of every dollar of the care provided under the waiver.
As it stands, though, the state will end up paying 28 percent of the cost of care, if the waiver is approved by state legislators and federal regulators.
No churning allowed
From October 2019 until March, Medicaid enrollment was pretty consistent, at an average of 2,187,059 beneficiaries per month.
In April, that number started climbing to 2,224,714. Advocates and officials expect that number will rise further as newly unemployed workers start applying for benefits. But most of those newly unemployed won’t qualify for the program, which strictly limits eligibility.
Richard said he expects to see enrollment start to tick up soon, but it’s been slower than usual because many county social service offices are closed.
“People are trying to do Medicaid from home not from county offices,” Richard said.
There’s a lot of paperwork involved with enrolling for Medicaid, and the disruption of county offices is slowing the process more.
“Usually people will come in and it’s not happening,” he said.
Richard said that numbers will also start climbing because, under the new rules associated with federal stimulus dollars, the state is prevented from kicking people off of the program, even if they’re no longer eligible.
So, the 40,000 people or so who usually “churn,” or cycle off of the program will stay as part of the beneficiary pool. There, some of the newly unemployed will join them, or rather that thin sliver of the newly unemployed.
Prior to a public health emergency being declared on Jan. 31, for every Medicaid dollar spent in the state, the federal government picked up 66 cents of the cost.
But under stimulus bills passed by Congress, the federal government will now pick up about 72 cents of each dollar spent. While a 6.2 percent increase sounds small, for a program that cost about $14 billion in state and federal funds in the last full fiscal year, that additional match would have been about $860 million in spending.
The first COVID-19 stimulus bill passed by Congress in early March, the Families First Coronavirus Response Act, included the extra matching money. In exchange for the extra dollars, states’ Medicaid programs now must cover the cost of testing, services and treatment for COVID-19, for beneficiaries. That includes the cost of vaccines and any specialized equipment or therapies those patients might need. Under these same rules, North Carolina is prohibited from imposing any cost-sharing requirements, such as copays or deductibles for that care.
The state started receiving those enhanced rates in late March and allowed states to backdate the increased rate to Jan. 1, 2020. The higher rate will continue until the federal health and human services secretary declares the public health emergency to be over, which could be as late as some time in 2021 or 2022.