Medicaid Premiums & Work Requirements: A Prescription for Higher Costs and Lower Health Insurance Coverage

November 7, 2017

Medicaid Premiums & Work Requirements: A Prescription for Higher Costs and Lower Health Insurance Coverage

This post was last updated on December 8, 2021. As new policies are announced, FPI will update this page.

As Florida’s response to COVID-19 takes front and center, concern grows for low-income families who struggle to take precautions against the spread of the virus. Although Congress has passed the Families First Coronavirus Response Act to address, at least in part, the public health crisis and economic fallout from COVID-19, many barriers continue to keep struggling families from accessing the assistance they need during the pandemic. As Florida initiates policies implementing the Act and addressing other barriers to the safety net, FPI will update this form. When available, hyperlinks are provided to agency documents or statements that provide greater detail about the new policy.
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On March 22, 2020, FPI and 44 other organizations sent a letter to Governor DeSantis, leadership in the Legislature and agency heads to urge action on 47 specific policy changes to reduce unnecessary barriers for Florida’s safety net programs in response to the COVID-19 pandemic. See the letter here.

Abstract

Recent proposals to impose work and premium requirements on Medicaid beneficiaries pose a significant threat to health coverage for the most vulnerable Floridians. They would also add new costs and uncompensated care burdens for state and local governments, safety net providers and privately insured residents. Lawmakers should instead look to commonsense Medicaid policies with a track record of improving access to care.

During the 2017 state legislative session, proposed legislation would have imposed work and premium requirements as conditions of Medicaid eligibility. Although the bill did not pass, the same or similar proposals are likely to re-emerge in 2018.

Executive Summary

Decades of research and experience with other safety net programs show that these requirements, as conditions of Medicaid eligibility, run counter to the overall purpose of the program. Medicaid was created to provide low-income individuals and families access to health care services. Instead, these proposals would likely deter thousands of uninsured Floridians from initial enrollment and terminate eligibility for thousands of participants.

These requirements would also add significant new costs and uncompensated care burdens for state and local governments, safety net providers and privately-insured Floridians.

Proposed Medicaid work requirements are largely driven by false stereotypes. In fact:

Most Medicaid recipients who can work are already working.

Years of experience with the Temporary Assistance for Needy Families (TANF) program, including Florida’s program, demonstrate that Medicaid work requirements would not result in long-term stable employment for most participants or lift them out of poverty.

Medicaid coverage enables people to work or seek work because they can stay healthy or address health problems, which are often barriers to employment.

While the 2017 legislation exempted certain categories of beneficiaries from work requirements, such as people with disabilities, research shows that exemptions are costly to implement and not effective in protecting vulnerable participants.

Women, minorities, people with limited education and those with serious health problems particularly risk losing coverage due to work requirements.

Likewise, decades of research show that Medicaid premiums have deterred enrollment and resulted in loss of coverage. For example:

In Florida, Medicaid financial eligibility is extremely restrictive; most participants are very low-income and struggle to afford minimal basic necessities.

Florida passed a Medicaid premium requirement in 2012, which was never implemented. One study projected that 800,000 children and their parents would have been dropped from the program because they could not afford a $10 monthly premium.

Premiums cause more people to cycle on and off the program. This cycling increases administrative costs and increases the average cost of care because healthier people are less likely to re-enroll after cancellation.

Premiums result in more uninsured families, which increases uncompensated care costs. These costs are shifted to state and local government, as well as health care providers.

Florida has made great progress reducing the number of uninsured, a steady decline from 20 percent in 2013 to 12.5 percent in 2016. Adding premium and work requirements to Medicaid eligibility would be a step backwards, having the harshest impacts on children in low-income families and their parents.

Downloadable Resources

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American Rescue Plan Act Changes. The American Rescue Plan Act of 2021 extended PEUC and PUA benefits through the week ending September 6, 2021. It also increased the maximum duration of PEUC benefits ($300 a week) to 53 weeks and the maximum duration of PUA to 79 weeks. Although PEUC and PUA did not end until September 6, 2021, Florida withdrew from the Federal Pandemic Unemployment Compensation Program (FPUC) effective June 26, 2021. FPUC provided persons who were out of work due to COVID-19 with an additional $300 a week in unemployment insurance.

DEO says that, after September 6, 2021, claimants will still have 30 days to submit an application for PUA benefits and that it will continue to pay eligible claimants the PUA and PEUC benefits they are owed for weeks of unemployment through the week ending September 4, 2021. New applications for PUA must be accepted through October 6, 2021, although limited exceptions to the deadline are allowed as stated here.

Reemployment Assistance weeks increased January 1, 2021. DEO determines the maximum number of weeks available to RA claimants based on a statutory formula that looks at the average unemployment rate for the most recent third calendar year quarter (i.e., July, August, and September). Based on the recent uptick in unemployment, the maximum number of weeks for RA will be increased to 19 weeks after 1/1/2021.

RA work-search and work registration requirements reinstated on May 30, 2021. Persons filing an application for RA benefits beginning March 15, 2020, are not required to complete work registration in Employ Florida through May 29, 2021. In addition, work search requirements for individuals requesting benefits for the weeks beginning March 15, 2020, were also reinstated on May 30, 2021.

Quarter change reporting instituted. DEO is requiring that Floridians receiving Pandemic Unemployment Assistance (PUA) or Pandemic Emergency Unemployment Compensation (PEUC) either reapply for assistance or complete a Quarter Change Questionnaire. DEO’s Fact Sheets and step-by-step video guides about quarter change reporting are here. According to DEO, this is because the federal government requires Florida to determine, on a quarterly basis, whether individuals who are currently receiving PUA or PEUC are eligible for Reemployment Assistance benefits.

‍RA biweekly reporting requirements reinstated. Although previously waived, biweekly reporting was reinstated effective May 10, 2020. DEO’s guide to claiming weeks is here.

Mobile app deployed. DEO has deployed a mobile app for RA applications.

Wait week waived. DEO waived the wait week for Reemployment Assistance through June 26, 2021 .

Claimants allowed to modify application date. DEO says that, because Floridians have had a hard time applying for Reemployment Assistance due to no fault of their own, claimants can request to modify their claim filing effective date:” According to DEO, back-dating only applies to claimants who attempted to apply and were not able to file a claim between the weeks of March 9, 2020, to April 9, 2020. In those cases, the claim date can be adjusted to the date that the claimant originally tried to apply. To do so, DEO advises that claimants visit www.FloridaJobs.org and select the link “Request to Modify Claim (Application) Filing Effective Date."

DEO to allow RA applicants to file using paper applications. On April 2, 2020, the Governor issued an executive order allowing RA applicants to use paper applications to apply, reassigning state agency staff to assist with RA efforts, authorizing DEO to procure additional resources to accommodate the increased volume of applications, and directing DEO to identify a third-party company to collect and deliver hard copy applications to DEO. The paper application can be downloaded here. Paper applications can also be obtained at CareerSource offices, where assistance in submitting applications will be available. Some libraries are also offering application forms. Check with your local CareerSource office or library first. New applicants who wish to apply online should apply at FloridaJobs.org.

DEO to begin answering claim-specific questions. Effective 4/20/2020, DEO says that it began answering the claim-specific questions of those who call 1-833-353-6799. In addition, DEO also has an online contact form for claims-specific questions here. For general questions that are not claim-specific, DEO asks that callers call 1-833 FL APPLY (1-833-352-7759) 8:00 a.m. - 5:00 p.m. on Satur

Updates from DEO on PUA CARES Act assistance. DEO issued guidance governing Pandemic Unemployment Assistance (PUA) for Floridians who have exhausted their RA benefits as well as self-employed, contract employees and gig workers who do not qualify for RA. To receive PUA, a claimant’s job must have been directly impacted by COVID-19.

In the guidance, DEO directs workers who have not yet applied to www.FloridaJobs.org and instructs them to select “File a Claim” to complete an application. DEO says that PUA applicants must file for Reemployment Assistance benefits before filing for PUA and tells workers who applied before April 5 to apply again. DEO also says that workers who filed a claim on or after April 5, 2020, but who have been given a monetary determination of “Ineligible,” should check CONNECT for a message to apply for PUA. For more details about applying and eligibility, go here.

PUA provides up to 79 weeks of benefits.

As of April 23, 2020, DEO says that applicants for Federal Pandemic Unemployment Assistance (PUA) must fill out a regular RA application and that the CONNECT system will prompt the applicant to fill out an additional PUA application once they are determined ineligible for regular Reemployment Assistance benefits. Here is a link to DEO’s instructions to PUA claimants for what to do after they file their PUA application, as well as their rights and responsibilities.

DEO has posted a video tutorial about PUA here.

DEO announces extended benefits. DEO announced implementation of Extended Benefits (EB), a federal UI program, in December 2020. Extended Benefits provides up to an additional 6 weeks of benefits to eligible individuals who have exhausted their RA and PEUC benefits during periods of high unemployment.

Resources and guidance. For a list of resources and guidance from the United States Department of Labor on unemployment insurance and COVID-19, go here.

For DEO’s “Reemployment Assistance Frequently Asked Questions and Additional Resources,” updated 4/23/2020, go here.

For DEO’s latest claims data, go here.

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Emergency allotments (EA) ended. DCF automatically supplemented SNAP allotments of current recipients up to the maximum for a household’s size for July 2021. However, EA was discontinued beginning August 1, 2021.

‍SNAP benefits increased by 15 percent through September 2021. Floridians who participate in SNAP to put food on the table will receive a temporary 15 percent supplement to SNAP under COVID relief passed by Congress and extended by the American Rescue Plan Act through September 2021.

FNS permanently increases SNAP through revamp of the Thrifty Food Plan. Effective October 2021, FNS has mandated a permanent increase to SNAP through a revamp of the Thrifty Food Plan. DCF says that the increase amounts to about 6% for Floridians.

‍Florida to roll out the Summer Pandemic Electronic Benefit Transfer program (Summer P-EBT). USDA has approved Florida’s plan for Summer P-EBT. Qualified children include those who were eligible for free or reduced price meals last school year or who became eligible over the summer, as well as children under 6 who participate in SNAP. The program will provide $375 in food assistance per child to make up for meals kids lost over the summer when school was not in session. DCF says that it hopes to begin issuance on November 24, 2021. However, DCF cautions that eligible households should anticipate a staggered disbursement through the beginning of 2022.

DCF estimates that almost 3 million children will qualify for Summer P-EBT.

DCF has an online form for families to fill out if they dispute what is happening with their child's P-EBT benefits. DCF also says that families can call 1-833-311-0321 if they have questions about a student's P-EBT benefit.

‍Important links:

DCF's P-EBT frequently asked questions
P-EBT FAQs and P-EBT for National School Lunch Program from Florida Department of Agriculture and Consumer Services'
Food and Nutrition Service P-EBT State Guidance‍

Time limits suspended. SNAP time limits are suspended during the COVID-19 public health emergency. No one in Florida should be barred from SNAP due to time limits, even if they exhausted their time limit in the past.

Florida granted waiver to allow families to purchase groceries online. DCF has been granted a federal waiver to permit the State of Florida to launch a pilot project statewide effective April 21, 2020, that allows families to purchase groceries online with their Electronic Benefit Transfer (EBT) card instead of going into stores.

At present, participating retailers are Walmart, Amazon, Aldi, BJ’s Wholesale Club, and Publix. DCF cautions, however, that EBT cards cannot be used for delivery fees.

For more information, see DCF’s questions and answers about online purchasing with SNAP.

‍What about Disaster SNAP (D-SNAP)? Although a COVID-19 disaster declaration has been declared at the federal level, no D-SNAP program has been approved by the President or initiated as of now. Disaster Supplemental Nutrition Assistance Program (D-SNAP) is linked to a federal declaration of disaster approving the program.

For a list of current SNAP waivers for Florida from USDA, go here.

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No Medicaid terminations from March 2020 through the end of the federal public health emergency. The national public health emergency has existed since January 27, 2020 and has been renewed by the Secretary of the U.S. Department of Health & Human Services in 90-day increments since that time. The most recent renewal is effective July 20, 2021.

On March 31, 2020, AHCA alerted providers and DCF posted on the ACCESS website that:

No Medicaid recipient will lose Medicaid eligibility during the COVID-19 public health emergency (unless the individual is no longer a state resident or request voluntary termination); under the newly enacted Families First Coronavirus Response Act, a state is prohibited from ending coverage for recipients enrolled as of March 18th for the duration of the public health emergency if the state opts to obtain an enhanced federal Medicaid match.

AHCA is working to notify recipients who may have received a termination notice in the month of March that their benefits will be reinstated.

An FAQ released by federal CMS provides some examples of Medicaid eligibility groups protected under these "no termination" requirements including: former foster care youth aging out when they turn 26; youth aging out of children's eligibility when they turn 19; individuals who become ineligible for SSI; individuals no longer qualifying for Qualified Medicare Benefits (QMB). In a May 5, 2020 update, CMS states that this “no termination” requirement also applies to medically needy individuals determined eligible during the public health emergency even if they do not continue to meet their monthly share of cost in subsequent months. This protection extends through the last day of the month the public health emergency ends.

On October 28, 2020, federal CMS issued a new interim final rule weakening the continuous coverage, “no termination” requirement. In states like Florida that have opted to cover full benefits for lawfully residing children in the first 5 years after entry into the United States, once they turn 18, states are now required to limit their coverage to emergency services. In addition, states are now permitted to reduce optional benefits such as dental coverage or increase cost-sharing such as requiring nursing home residents to contribute more to their costs of care. But in Florida this type of change would require the Legislature to amend state Medicaid law.

Redetermination/recertification times are reinstated. As of October 1, 2020 AHCA's website is alerting recipients that the Department of Children and Families is now mailing letters for case reviews to check if a household is still eligible for Medicaid and/or Medically Needy. AHCA is urging people receiving these letters to take steps now to re-apply. But note, Medicaid coverage will not end during the COVID-19 Public Health Emergency. In January 2021 DCF conducted one-year “automated renewals” for people whose sole income is social security and SSI and are enrolled in an SSI-related Medicaid program (e.g., MEDS/AD, Medically Needy and Medicare Savings Programs). People getting VA income were not included in the automated renewal.

Extended application time. Effective with applications filed in February 2020, the time for submitting documentation required to process an application is extended for 120 days from the date of the application and eligibility will still be effective the first day of the month the application was received. Effective July 1, 2021, this policy has been rescinded. Medicaid applications submitted on or after July 1, 2021 may be denied on the 30th day after application or the day after verification information is due. Applications filed prior to July 1, will be allowed 120 days to provide requested verification to establish Medicaid eligibility.

‍Exclusion of additional unemployment payments in determining eligibility. The $600/week of additional unemployment insurance payments under the CARES Act will not be counted as income in determining Medicaid eligibility. (However, these payments will be counted as income in determining marketplace subsidy calculations.)

Coverage of Medicaid services during the state of emergency

Coverage of all medically necessary services to COVID-19 testing and treatment.

Waiver of limits on services that must be exceeded to maintain the health and safety of recipients diagnosed with COVID-19 or when necessary to maintain a recipient safely in their home

Waiver of prior authorization requirements for hospital, physician, advanced practice registered nursing, physician assistant, home health services and durable medical equipment and supplies. As of June 19, 2020, AHCA reinstated prior authorization requirements for all of these services.

Waiver of copayments for all services

Waiver of limits on early prescription refills, except for controlled substances

Coverage of a 90-day supply of maintenance prescriptions when available at the pharmacy

Reimbursement of out-of-state providers providing medically necessary services to Florida Medicaid beneficiaries. As of July 1, 2021, the availability of provider “provisional enrollment” for in-state and out-of-state providers will end.

120 day extension of time to request fair hearings. As of July 1, 2021, the extended timeframe ends and the standard timeframes available to recipients to submit an appeal or request a hearing will be reinstated.

Delay of fair hearings only in those instances when the recipient is continuing to receive services pending the outcome of the hearing

COVID-19 Vaccines for Medicaid Enrollees. In an executive order published March 16, 2021 Governor DeSantis revised the vaccine distribution plan, which applies to the general public including Medicaid enrollees, to lower the age requirement to 40 effective March 29, 2021 and then effective April 5, 2021 all Floridians are eligible to receive any COVID-19 vaccination approved by the Food and Drug Administration.

Medicaid enrollees eligible to receive the vaccine may visit myvaccine.fl.gov to find a location distributing the vaccine and to schedule an appointment.

On March 12, 2021, AHCA published instructions for Medicaid enrollees on how to obtain Medicaid transportation once they have scheduled an appointment for a vaccine. AHCA states: "Florida Medicaid will take you to get the COVID-19 vaccine at no cost. All you need to do is set up a time to get your vaccine. Next, let your Medicaid plan know you need a ride and they will take care of the rest. If you are not enrolled in a plan, call the Medicaid Helpline at 1-877-254-1055 to find out the name and phone number for a transportation service."

The state has also recently launched a new email system to help bring COVID-19 vaccines to homebound seniors. Seniors will be able to sign up to have the vaccine come to them by emailing a request to HomeboundVaccine@em.myflorida.com.

AHCA has posted Medicaid Alerts and FAQs providing more detail on Medicaid service changes in response to COVID-19. They address a wide range of topics including, but not limited to: telemedicine guidance for medical, behavioral health, and early intervention services providers; long-term care provider network flexibilities allowing more types of providers to deliver specified long term care services; and continuity of care for adult day care center enrollees during the time these centers are closed.

AHCA is loosening coverage restrictions for behavioral health services. Effective May 5, 2020, all prior authorization requirements for mental health or substance use disorder treatment are waived and service limitations (frequency and duration) are lifted. For behavioral analysis services, current authorizations will be extended through an "administrative approval process" which does not require providers to reassess beneficiaries currently getting services. Effective July 1, 2021 service limits will be reinstated for behavioral health services and effective July 15, 2021 Medicaid prior authorization requirements will be reinstated for behavioral health services.

Per a May 29, 2020 provider alert, during the state of emergency AHCA will be reimbursing providers for telemedicine well-child visits provided to children older than 24 months through age 20. Providers are directed to actively work to schedule follow-up in-person visits to administer immunizations and other physical components of the exam which cannot be accomplished through telemedicine.

The public charge rule will not be applied to immigrants’ use of Medicaid benefits for COVID-19 testing and treatment.

Coverage of home and community-based waiver services (HCBS) - In response to the public emergency, Florida obtained approval from the federal government to make changes in HCBS waiver programs, including the Long Term Care and Developmental Disabilities programs. The changes are effective retroactively from January 27, 2020 to January 26, 2021. Details can be found here. They include, but are not limited to:

permitting virtual evaluations, assessments and care planning meetings in lieu of face to face meetings and use of electronic signatures;

lifting service limits in order to address health and welfare issues of enrollees;

adjusting service prior authorization requirements;

temporarily expanding the settings where services can be provided;

allowing payments for support services provided to enrollees in hospital or short- term institutional settings; and

prohibiting visitors in certain residential settings to minimize the spread of infection.

Note on COVID-19 testing, treatment, and vaccines for the uninsured. Florida has not opted to receive 100 percent federal Medicaid funding for COVID-19 testing of people without health insurance. Under the 2021 American Rescue Plan Act this option has been expanded to cover COVID-19 treatment and vaccines for the uninsured as well. Since the state has not taken up this option Floridians must look to an uneven patchwork of free testing, treatment, and vaccine resources scattered around the state. AHCA advises that uninsured people may receive free testing from their county health department or a federally qualified health center and that “many communities provide testing for free for individuals who do not have insurance. Please [click here] to find a test site in your area. Uninsured individuals should ask before the test whether testing is free of charge." There are no state agency instructions on where uninsured people can receive free treatment. However, more information on possible sources for free treatment is available here.

Residency proof no longer required at some vaccine sites, “paving the way for migrants.” - On April 29, 2021 Surgeon General Rivkees issued a new public health advisory specifying that COVID-19 vaccines are available to “a Florida resident” or someone “who is present in Florida for the purpose of providing goods or services for the benefits of residents and visitors of the State of Florida.” This new policy applies to all state-run and federally supported vaccination sites. It rescinds an advisory issued in January that had restricted vaccinations to people who could show proof of Florida residency

2021 unemployment compensation claimants can access free or reduced cost health insurance through the ACA marketplace. The Affordable Care Act (ACA) Marketplace was re-opened in February 2021 to give people who need health insurance a new “special enrollment" opportunity to get covered. The 2021 American Rescue Plan eliminated or vastly reduced premiums for many people with low or moderate incomes.

Starting July 1, 2021, people who received or have been approved for unemployment compensation for any week beginning in 2021 can access free or reduced cost comprehensive health insurance plans through the ACA marketplace. This benefit is available regardless of someone's current income. To get this benefit, people must enroll in the marketplace no later than August 15, 2021. For help with enrollment, contact Covering Florida at 877-813-9115.