On November 2, 2015, the Centers for Medicare and Medicaid Services (CMS) approved Montana's request under Section 1115 of the Social Security Act to implement its Medicaid expansion. Referred to as the Health and Economic Livelihood Partnership (HELP) Program, the five-year Demonstration will cover up to an estimated 70,000 new adults. CMS also approved the State's companion Section 1915(b)(4) Waiver request, allowing Montana to selectively contract with a Third-Party Administrator (TPA) to administer healthcare services to new adults under the Demonstration. Enrollment for the HELP Program began on November 1, 2015, with coverage beginning on January 1, 2016.
Most new adults will receive services through the TPA, and will be subject to co-payments and premiums. Some individuals will be excluded from the TPA, including: the medically frail; individuals who live in a region, including an Indian reservation, where Montana's TPA is unable to contract with a sufficient provider network; individuals who require continuity of coverage that is not available or could not be effectively delivered through the TPA; and individuals with income below 50 percent of the Federal Poverty Level (FPL).1
Key Features of Montana's Medicaid Expansion
Premiums. New adults receiving services through the TPA are required to pay premiums equal to 2 percent of their household income. Individuals with incomes from 101 to 138 percent of the FPL who fail to pay premiums will be given a 90-day grace period, after which they will be dis-enrolled from coverage and may re-enroll upon payment of premiums owed or upon a quarterly debt assessment against their State taxes. Individuals with incomes at or below 100 percent of the FPL who fail to pay premiums will incur a debt to the State, but will not be dis-enrolled from coverage.
Co-payments. New adults are required to pay the maximum co-payments allowable under federal law. For the first 12 months of enrollees' coverage in the HELP Program, the State will credit their incurred co-payments against premiums such that these individuals will not have to pay co-payments until the value of accumulated co-payments exceeds 2 percent of their income.
Additionally, the following services and service categories are exempt from co-payments: primary, secondary and tertiary preventive care services; family planning services; pregnancy-related services; immunizations; emergency services; and medically necessary health screenings ordered by a healthcare provider.
Third-Party Administrator. Montana is using a TPA arrangement to administer its Medicaid expansion. The TPA will be responsible for establishing networks of healthcare providers, facilitating provider reimbursement on behalf of the State, collecting enrollee premiums, tracking cost-sharing, and implementing a Wellness Program. Services will be reimbursed on a fee-for-service basis, and the TPA will be paid an administrative fee for its services. In October 2015, Montana awarded its TPA contract to Blue Cross Blue Shield.
12 Months Continuous Eligibility. The State also received approval to establish 12-month continuous eligiblity for all new adults with incomes up to 138 percent of the FPL.
Montana is the seventh state to receive CMS approval for an alternative expansion model under Section 1115 Waiver authority, following in the footsteps of Arkansas, Indiana, Iowa, Pennsylvania, Michigan, and New Hampshire.2 All of these states share some common waiver features—largely related to imposing cost-sharing in the form of premiums and maximum co-payments. Montana is the first state to receive approval to impose both premiums and maximum allowable co-payments on Medicaid enrollees with incomes below 100 percent of the FPL. However, CMS imposed a number of terms and conditions intended to mitigate the impact of cost-sharing on these beneficiaries: individuals with incomes below 100 percent of the FPL will not be dis-enrolled from coverage for failure to pay premiums; the State will credit enrollees' incurred co-payments such that these individuals will not have to pay co-payments until the value of accumulated co-payments exceeds 2 percent of their income; preventive care services, including secondary and tertiary preventive care are exempt from co-payments; and the federal requirement that no family will pay more than 5 percent of their household income in co-payments and premiums will apply.