Hearings across the state are giving Nebraskans a look at the state's plans for Medicaid expansion.

Nate Watson, Nebraska Medicaid deputy director for policy and regulations, stopped by the Star-Herald on Tuesday to talk about Medicaid expansion. Watson has been in the policy role for about a half-year, but previously served as a senior attorney for the Nebraska Department of Health and Human Services. He has been traveling across the state as public hearings are held as the state seeks a waiver on Medicaid rules. A hearing was held in Scottsbluff Tuesday, the first of hearings planned in the state as part of the waiver process. Nebraska officials were also on hand during a hearing in front of the Nebraska Legislature on Friday.

Voters passed Initiative 427 passed in November 2018, opting to expand Medicaid to “low-income, able-bodied adults, of working age, those people 19 to 64, who traditionally haven’t been eligible for Medicaid.” Watson explains that prior to the initiative, Medicaid was only available to disabled persons, children in low-income families and pregnant women.

Nebraska’s Medicaid expansion will be called “Heritage Health.” Watson explained that the Nebraska DHHS is seeking a waiver as it is opting to offer two tiers of Medicaid coverage under expansion.

The initiative required officials to file state plan amendments (SPA). That was done by April 1, and a “concept paper,” detailing how they would expand

In the process that is underway now, the state is seeking a (1115 demonstration) waiver from “default, baked in rules,” Watson said, many of them go back to when Medicaid first started in 1965. “A lot of those rules don’t really make a lot of sense in 2019. Certainly, health care, and even just life expectancy, society, has changed quite a bit since 1965.”

Nebraska’s Medicaid expansion plan is unique compared to other states, Watson said.

The state cites its sought-after waivers as “innovations.”

“We think we can provide health care to persons of limited means better than the default rules. It will lead to better, most cost effective, outcomes,” he said.

The state is proposing to implement its Medicaid expansion in two tiers of coverage in its “Heritage Health Adult” Medicaid program..

A basic tier would provide 13 mandatory services, as required by the federal government, and three additional services. To access basic Medicaid services under Nebraska’s Expanded Medicaid, eligible persons will be ages 19-64, not currently enrolled in Medicaid, a citizen or permanent resident, and meet income levels, which is 138 percent of the poverty level (less than $17,000 a year for an individual).

Many states have work requirements, however, Nebraska won’t have a work requirement in place to access that basic tier of care. However,

However, Nebraska is also seeking — which Watson says is a key part of the waiver being sought — to provide a second tier. That tier, called “Prime,” would include dental and vision coverage and coverage for over-the-counter medications.

To have access to coverage under this tier, clients will have to meet certain requirements.

Clients will be required as part of a “community engagement requirement” to be working, actively looking for employment, attending college or participating in volunteer service. There are exceptions, and of course, the requirements don’t apply for those being provided services under traditional Medicaid.

Watson says the Prime tier serves the purpose of being an incentive for clients to use health care services.

“We want you to use it (health care coverage), and use it well,” he said.

Wellness activities are also required: picking a primary care provider, visit that provider at least once a year, and participate in care and case management. Some persons have infrequent doctors visits, if at all, and do not have a doctor or know where to begin with a doctor.

Under Nebraska’s proposed Medicaid expansion, Watson said, clients will be encouraged by the requirements. The state is seeking “to move the needle and help people get healthier.”

To access the prime tier of Heritage Health Adult, one of the requirements will also have to meet “personal responsibility requirements.” One requirement is that clients do not miss more than three appointments within a six-month period. Watson said the intent is to encourage clients to keep regular health care appointments, as well as find specialists that can provide the care they need. Some people need assistance making appoints and needing transportation to appointments. Medicaid will provide assistance in both those areas.

Nebraska has looked at other states and feel that the incentive is needed to help improve care. A lot of folks wait until health care issues have become severe and they need to go to an emergency room.

“They get eventually get the care, but not when it would have done the most good.”

Waiting until health issues become more severe also increases costs, Watson notes.

Watson said, doctors who have chosen not to participate in Medicaid also cite that patients do not show up for appointments, which can cost doctors money as they plan for appointments and staffing.

It’s hoped that personal responsibility requirement under the Prime level of care will reduce those no-shows and improve the health care outcomes in the state. Other personal responsibility requirements include not dropping employer-provided insurance, if it is affordable, and reporting material changes, such as an increase in wages, within 10 days of a change.

The state’s ultimate goal is to provide coverage for people of limited means. However, the state has also sought to empower people with its proposed “innovations.”

“Our ultimate goal is to not have people stuck on Medicaid for their whole life,” Watson said. “... We think by incentivizing them to use that care — get to the doctor early and get that ongoing care — they are going to be healthier, it’s going to more cost effective coverage so we can serve more people with that limited amount of money, and eventually, if we help them move into work and get those job skills, they won’t need Medicaid any longer.”

Nebraska will begin taking applications for its expanded Medicaid coverage on Aug. 1, 2020, and benefits will begin on Oct. 1, 2020.

A common question has been about the length of time that it is taking the state to implement Medicaid expansion. It’s a commonly-cited complaint by advocacy groups that advocate for low-income individuals.

However, Watson said, it’s taking time for the state to implement Medicaid expansion in a responsible manner.

“The governor tasked us with taking it right, to provide a better, more cost effective system that is built for Nebraska,” he said. “That’s why we’re taking the time to build it right.”

It takes time to hire and train additional employees to provide additional services. It will also take time to improve technology, such as computer systems for proper coding, will also take time.

Officials are currently in the process of recruiting additional doctors and providers to participate in the Medicaid system. Under Medicaid expansion, reimbursement rates from the federal government for services will increase to 90 percent, up from the range of 50 percent under traditional coverage for non-expansion rates. That may bring more physicians into the system who had previously declined to see Medicaid patients. In some areas, the state will be actively recruiting physicians to provide.

Federal law requires two public hearings prior to submitting the waiver application. Hearings being held across the state are not only a requirement of the waiver application, but allow Nebraska officials to talk the public about the plan and answer questions.

Comments from the public hearing will be reviewed and officials will consider and respond to those comments in the application. Anyone who was unable to attend the Scottsbluff hearing, or other hearings throughout the state, can submit written comment. Information on calling into the remaining public hearings, in Norfolk and Omaha, are available online: http://dhhs.ne.gov/Pages/Medicaid-Expansion.aspx.

Comments and questions can be submitted via email at DHHS.HHAWaiver@Nebraska.gov, or mailed to: Department of Health and Human Services, Nebraska Medicaid, ATTN: HHA Waiver, 301 Centennial Mall South, P.O. Box 95026, Lincoln, Nebraska 68509-5026.

State officials are hoping the Medicaid waiver will be approved by April.

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