Indiana House committee greenlights amended Medicaid work requirements

A bill that would tighten Medicaid eligibility and add work requirements for certain programs was amended and passed out of the Ways and Means Committee in just under an hour on Wednesday, moving on a party-line vote.

Earlier that day, a separate committee advanced two other bills impacting the state’s low-income health coverage program, with one seeking to establish a “diversion” program to the state’s fastest-growing expense.

Senate Bill 2, authored by Sen. Ryan Mishler, would quadruple the administrative workload of the Family and Social Services Administration by requiring quarterly eligibility checks, a concern for some committee members.

“Those dollars that we’re putting toward administrative costs could be applied to services,” said Rep. Peggy Mayfield, R-Martinsville.

House sponsor Rep. Brad Barrett, R-Richmond, assured his colleagues that FSSA was “comfortable” with the workload increase, swaying Mayfield.

“I feel comfortable that you feel comfortable that the agency has its authority already … to make adjustments on its own with the legislation,” Mayfield said, speaking to a later, related amendment.

That wasn’t enough for all committee members, particularly Democrats. Rep. Tonya Pfaff, of Terre Haute, pointed to her rural constituents. Rural Hoosiers make up a significant chunk of Hoosiers on Medicaid who may not have the tools to comply with quarterly reviews.

“A lot of my community is rural and doesn’t have access to broadband,” said Pfaff.

Sixteen Republicans voted in favor, overcoming the opposing votes from seven committee Democrats.

The amended bill

As it arrived in the House, the proposal already allowed for eleven exceptions to the work requirement, including pregnant Hoosiers and those seeking treatment for substance abuse. The language applies to just the Healthy Indiana Plan, which primarily covers working-age Hoosiers with low-to-moderate incomes.

Disabled and elderly Hoosiers would not be impacted.

But a large amendment added one more exception for full-time students while also clarifying that someone who worked and volunteered for a combined 20 hours a week would also meet the minimum requirements.

Barrett also focused tweaks to a prohibition on advertising the program, allowing the agency discretion to reimplement advertising in the future, as well as presumptive eligibility.

Presumptive eligibility, Barrett said, meant “intake at hospitals have the ability to run a quick screen and determine whether or not that patient seeking services has eligibility.”

“We found that there’s a high risk … a high rate of error in that,” Barrett continued.

He said lawmakers worked with stakeholders to use retroactive eligibility instead, meaning that patients found to be eligible will then have their services for the last 30 days paid for once they’re accepted.

The newly amended bill will also now has an expanded definition of caregiver, after the committee accepted a suggestion from Rep. Ed Clere, R-New Albany. Now caregivers will also include spouses in addition to parents. The amended language also explicitly protects Medicaid coverage for Hoosiers receiving caregiving under other state programs.

But Republicans rejected three edits put forth by Democrats, not including two that were voluntarily withdrawn. The amendments, all authored by Rep. Greg Porter, would have removed work requirements entirely, eliminated the advertising prohibition and reduced eligibility determinations to twice annually.

Rep. Cherrish Pryor, also an Indianapolis Democrat, urged caution when it came to rescinding health coverage for Medicaid enrollees.

“It’s better safe than sorry,” Pryor said. “Because we are talking about the health of Hoosiers.”

Republicans pointed to dual benefits of the bill: reducing state expenses and preserving the program for “deserving” Hoosiers.

“I think it’s going to make a significant difference on the cost side, as well as helping people out, so I’m actually hopeful,” said Rep. Jack Jordan, R-Bremen.

The previous version of the bill included a cap on 500,000 Hoosiers, below the 700,000-plus receiving coverage now, as well as a three-year limit. Both provisions have been stripped from the bill though it gives FSSA the latitude to limit enrollment on its own.

Other health bills

Clere, who proposed the caregiver amendment on Senate Bill 2, had two other bills up in committee earlier on Wednesday: one that sought to add a caregiving tier to a program for children with complex medical needs and another concerning a “Medicaid diversion” program.

Last year, FSSA opted to limit a state attendant care program after an unanticipated surge in demand from parent caregivers to medically complex children. The lack of guardrails on the program meant that some families made triple-figure incomes and reportedly worked 90-plus hours weekly.

Nearly all families have now moved from the attendant care program to Structured Family Caregiving, meaning they no longer receive payments based on an hourly wage. The latter program utilizes three tiers of daily stipends aligned with the level of care needed.

“House Bill 1689 requires FSSA to work with the (Division of Disability and Rehabilitative Services) Advisory Council to refine and develop plans for serving individuals requiring extraordinary care,” said Clere.

Jennifer Dewitt is the mother of Jackson, a 17-year-old with complex medical needs. She notes that other states have also created programs for complex care assistants, under which parents can certify and be paid through a nursing agency for their caregiving.

“This isn’t replacing a nurse, it’s going to be limited to family members … in many cases, this provides care when no nurses are available,” said Dewitt, part of the Indiana Families United 4 Care group representing parents. “We have data that shows that when parents are paid caregivers, hospitalization rates go down, saving the state significant amounts of money, and the reimbursement rate would be substantially less expensive than (registered nurse) services.”

Like many other families, Dewitt said she couldn’t secure a nurse to meet all of her Medicaid-approved hours.

Jackson is on a ventilator and also has seizures, meaning she can easily work in excess of 120 hours a week on his care, she said.

The bill also adds an ombudsman position to FSSA for individuals receiving disability services and requires FSSA to report annually on Medicaid home- and community-based waiver services.

House Bill 1391, on the other hand, would allow for a study to potentially realign coverage areas for senior care agencies, known as Area Agencies on Aging and allow certain service providers under the CHOICE program to not be Medicaid approved.

“I think we all agree that someone who’s doing pest control services, for example, probably doesn’t need to be a Medicaid provider,” said Clere.

But the bill also positions the CHOICE program, which stands for Community and Home Options to Institutional Care for the Elderly and Disabled, as a “Medicaid diversion program.”

“CHOICE predated the (Medicaid) waiver. But ever since there’s been a waiver, I would argue CHOICE has been effectively a Medicaid diversion program,” Clere said. “This bill formalizes that.”

The proposal creates a pilot program for CHOICE recipients served by senior care organizations to explicitly keep Hoosiers from needing Medicaid funding. That can include stopping falls and preventing medication mix-ups, the two biggest reasons Hoosiers enter long-term care.

Both of Clere’s amended bills moved out of a Senate health committee unanimously, though the latter will also need approval from the Senate Appropriations Committee.

The Indiana Capital Chronicle is an independent, nonprofit news organization that covers state government, policy and elections.