WHAT IS MEDICAID BUY-IN?
The term “Medicaid buy-in” is used to describe differently structured proposals, but all would create a way for some people who are not currently eligible for Medicaid to purchase Medicaid-like coverage. States may use different names to talk about these new coverage options, and depending on the state, it may not even be referred to as “Medicaid buy-in” at all.
Buy-in proposals aim to make available the relatively robust and affordable coverage Medicaid typically provides to people who don’t otherwise qualify. The goal is not to change the Medicaid program for those already eligible and enrolled.
In this context, Medicaid buy-in should not be confused with existing programs in many states that allow individuals with disabilities to buy Medicaid coverage if their income or assets would otherwise make them ineligible for Medicaid coverage.
Why IS MEDICAID AN APPEALING OPTION FOR CONSUMERS?
Medicaid is a familiar source of affordable health care for many families and communities, providing health care coverage to 19% of the U.S. population. Medicaid has evolved to fit the diverse needs of different enrollees, including children, parents, those receiving long-term care, people with disabilities and childless adults. Medicaid provides comprehensive coverage of benefits tailored to different groups of enrollees in the program with minimal cost sharing.
Medicaid beneficiaries are generally satisfied with their care, with Medicaid enrollees in a recent study rating their care a 7.9 on a scale of 0-10. People who became eligible for Medicaid under the Affordable Care Act’s expansion rate their coverage even more highly than those enrolling in Marketplace coverage. A Commonwealth Fund study in 2016 found that 77 percent of adults with marketplace plans and 88 percent of those newly enrolled in Medicaid were very or somewhat satisfied with their health insurance.
Why IS MEDICAID BUY-IN AN APPEALING OPTION FOR STATE POLICYMAKERS?
Medicaid buy-in proposals can also appeal to state policymakers for many different reasons. Medicaid is an efficient program, and while it occupies significant percentages of states’ budgets, when controlled for enrollees’ health status, Medicaid costs less than private insurance. Similarly, Medicaid’s per-enrollee costs have grown slowly compared to other payers. Medicaid buy-in proposals can be structured to help state policymakers achieve a range of goals and address varying priorities such as:
Increasing choice and competition: In 2019, 35% of counties will have only one issuer offering coverage on the Marketplace. Creating a way for consumers to purchase Medicaid coverage generates more competition in areas with few issuers, giving consumers more choices, and reducing the risk of bare counties with no issuers offering coverage.
- Increasing choice and competition: In 2019, 35% of counties will have only one issuer offering coverage on the Marketplace. Creating a way for consumers to purchase Medicaid coverage generates more competition in areas with few issuers, giving consumers more choices, and reducing the risk of bare counties with no issuers offering coverage.
- More affordable coverage: With lower per enrollee costs than private insurance, Medicaid offers a more affordable option to consumers, with lower premiums and out-of-pocket costs.
- Minimizing churn and disruption: People in the individual insurance market can experience “churn” as their income changes and they move between Medicaid and the private insurance market. Depending on the way it is designed, a Medicaid buy-in option could help minimize the disruption that consumers currently face when their circumstances change.
- State public option tool: With broad support for proposals to allow people to purchase Medicare coverage before age 65, pursuing Medicaid buy-in gives state officials a way to respond to their constituents’ interest in additional public coverage choices, especially when federal policymakers are unlikely to enact this type of option.
HOW WOULD A MEDICAID BUY-IN ACTUALLY WORK? WHAT WOULD BE COVERED AND WHERE WOULD I BUY IT?
Just as every state’s Medicaid program looks different, every state’s approach to a Medicaid buy-in will look different. The different reasons a state may pursue a Medicaid buy-In proposal will help to shape the way the proposal is structured.
State Health & Value Strategies, in partnership with Manatt Health, has laid out two primary design options that most states are considering for Medicaid buy-in: a state-sponsored option that people purchase through their state’s Marketplace that meets the same rules and requirements as other plans sold there, or a Medicaid buy-in outside of the Marketplace.
Medicaid buy-in plans likely won’t cover the full suite of benefits that some people receive through Medicaid, like long-term care services. However, Medicaid buy-in can be a way for a state to increase access to important benefits that are not always included in health insurance, like dental and vision care.
CAN MY STATE PUT IN PLACE A MEDICAID BUY IN PROGRAM WITHOUT INVOLVING THE FEDERAL GOVERNMENT?
Yes, it’s possible. A state could opt to design a Medicaid buy-in that does not require them to seek permission or approval from the Federal government. However, if a state wants to allow people to use their tax credits to purchase the Medicaid buy-in coverage on the Exchange and capture any savings, the state would need to receive permission from the federal government, in the form of a State Innovation Waiver, known as a 1332 waiver.
WHY NOT A MEDICARE BUY-IN PROGRAM?
While Medicare is a federal program, Medicaid is a federal-state partnership that is administered by individual states. States have a track record of proving they can solve problems when Washington DC can’t, and Medicaid buy-in is an approach that states can use now to expand access to affordable options. And with a Medicaid buy-in, states have the ability to develop a unique approach that is right for their state.
WILL I STILL BE ABLE TO SEE MY DOCTOR? OR WILL I HAVE TO CHANGE DOCTORS?
It depends. Not all doctors take all forms of insurance, so just like any other coverage, people would need to check to see if their doctor accepts the coverage they choose to buy.
IT CAN ALREADY BE CHALLENGING TO FIND A DOCTOR THAT ACCEPTS MEDICAID-- WOULD MEDICAID BUY-IN PAY DOCTORS THE SAME RATES AS CURRENT MEDICAID PROGRAMS?
States will need to determine how they pay providers as part of any Medicaid buy-in initiative and they will need to carefully consider whether enrolling additional customers in plans that tend to pay lower rates will result in sufficient provider participation and access to care. A new coverage option that attracts people currently enrolled in commercials plans that typically pay higher rates could require a different approach than one that primarily attracts those who are currently uninsured.
IS THIS A PUBLIC OPTION/ SINGLE PAYER?
Medicaid buy-in is a way for states to leverage a successful program to give people an additional affordable option. People could still choose to purchase different coverage if they wanted to. In many states, Medicaid programs contract with insurance companies to run the program, and states could choose to use that approach for a Medicaid buy-in.
WHO WILL BE ABLE TO BUY-IN TO THIS PROGRAM?
The eligibility for Medicaid buy-in will depend on the each state and how they design their program. Some proposals, for example, would allow any state resident to purchase Medicaid, while others may target the buy-in to certain populations or certain geographic areas.
HOW MUCH WILL IT COST? AND WHO IS GOING TO PAY FOR IT?
Much like eligibility, cost and funding will vary from state to state. Just as the name suggests, with a buy-in, people are paying for the cost of their coverage-- it is not a way for states to receive additional federal Medicaid funding. A state could provide financial assistance to make the cost more affordable if they chose.
WHAT OTHER PUBLIC OPTION APPROACHES ARE UNDER CONSIDERATION IN THE STATES?
Every state exploring this policy area will likely opt for a slightly unique approach. Some states may choose to build on particular aspects of their Medicaid programs, while others may build a buy-in on different programs. For example, several states, including Washington and Connecticut, are considering buy-ins that would allow people to purchase a Qualified Health Plan (QHP) on the Exchange.
HOW WOULD A MEDICAID BUY-IN AFFECT PEOPLE IN THE STATE CURRENTLY COVERED BY
While they may build on the infrastructure of a state’s Medicaid program, Medicaid buy-ins do not necessarily impact the coverage of those currently enrolled in Medicaid. That being said, any Medicaid buy-In proposal should carefully consider any potential implication for those already enrolled in Medicaid and ensure that there are no unintended consequences that could erode the current coverage and benefits available for those in Medicaid.
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