Two issues for NJ for Health Care Coalition:
1. Presumed eligible for Medicare? -- An abusive practice in NJ's ACA marketplace
1. AmeriHealth NJ and possibly other insurers in NJ's ACA marketplace are presuming marketplace enrollees over age 65 to be eligible for Medicare unless they prove otherwise by providing a letter from the SSA stating that they are ineligible for Medicare, and why. An AmeriHealth employee told me that NJ DOBI authorized this presumption, effective in April of this year. Here is what appears to be the rule change in question, albeit in proposed form. The below is from pg. 6 of Proposed Amendments to the NJ's Standard Health Benefit Plans in the individual market, published last fall:
The Board proposes to remove Medicare from the scope of the Coordination of Benefits Provision and add a provision addressing the effect of Medicare on individual coverage. This new provision clarifies the secondary status of individual benefits when a person is entitled to Medicare as well as addresses the obligation of the consumer to provide information regarding Medicare eligibility. The Benefits from Other Plans provision cross references the newly added provision.
2. I have not been able to locate a finalization of this rule in NJ's adopted amendments for individual health coverage or in the NJAC Sect. 11:20 Appendix Exhibits A and B (standard insurance contracts for the IHC) to which the adopted amendments refer. These documents, as far as I can tell, provide rules for priority of payment if an enrollee in an individual health plan is enrolled in Medicare, but not (as far as I can find) a stipulation that an insurer can presume an enrollee eligible for Medicare unless proven otherwise. But I have seen confirmation, via billing, that Amerihealth is doing this. And it's laid out in Amerihealth's benefits book:
3. There are almost 9000 over-65 enrollees in NJ's ACA marketplace. It's likely that nearly all of them are legally present noncitizens. If you do not have 10 years' work history in the U.S., you do not qualify for Medicare. The presumption of Medicare eligibility imposes a major administrative burden -- you have to apply for Medicare and submit the subsequent rejection letter. Otherwise, Amerihealth, and likely the other marketplace insurers in NJ, will make only fractional payments to providers for services provided to the enrollee.
4. I put in a journalist's query to CMS (I write a health policy blog) and was told that this practice appears to be illegal:
"In May 2023, CMS issued an FAQ clarifying the benefit coordination between individual health insurance coverage and Medicare. The FAQ clarifies that pursuant to the essential health benefits and actuarial value requirements under the Affordable Care Act, a health insurance issuer offering non-grandfathered individual health insurance coverage may not change the plan payment level or refuse to pay for otherwise covered services on the basis that an individual is eligible for Medicare but not actually enrolled in Medicare. The FAQ is available at https://www.cms.gov/files/document/benefit-coordination-and-medicare-eligibility.pdf.
CMS has been in contact with the New Jersey Department of Banking and Insurance (NJDOBI) regarding this issue. We recommend contacting NJDOBI for further information."
4. Here is the upshot in the CMS document linked to above:
Q: An individual is enrolled in non-grandfathered individual health insurance coverage and is eligible for Medicare but isn’t enrolled in Medicare. May the issuer change the payment level for or refuse to pay for covered services for which Medicare would have paid had the person been enrolled in Medicare?
No. In the absence of enrollment in other primary coverage (such as Medicare), an issuer offering non-grandfathered (non-grandmothered)2 individual health insurance coverage cannot take that other coverage into account when paying for covered services. Pursuant to the EHB and AV requirements under the Affordable Care Act,3 an issuer offering non-grandfathered individual health insurance coverage may not limit or exclude coverage based on the theoretical possibility of an individual’s enrollment in other coverage.4 Additionally, modifying a benefit design based on an individual’s eligibility for Medicare could be considered as violating federal non-discrimination prohibitions. We remind issuers that under regulations implementing the Public Health Service Act’s guaranteed renewability of coverage requirements, Medicare entitlement or enrollment is not a basis to nonrenew an individual’s health insurance coverage in the individual market when the renewal is effectuated under the same policy or contract of insurance.6 5 Therefore, non-grandfathered (non-grandmothered) individual health insurance coverage must pay for covered services for an enrollee who is (or is presumed) eligible for but not enrolled in other primary coverage, without taking that other coverage into account.
2. Medicaid Estate Recovery
The current bill is
S3759, introduced in May by Cryan,
referred to the Senate Health, Human Services and Senior Citizens Committee. We would send a similar letter to the one below.
Dear Assemblywoman Downey:
Thank you for sponsoring
A1023, limiting the authority of DHS to impose liens and seek recovery from Medicaid recipients' estates after death to enrollees who obtain LTSS, as well as limiting the scope of recovery. On behalf of the NJ for Health Care Coalition, I am writing to request a meeting to discuss plans to get this vital bill enacted.
At a time when new state and federal resources are being committed to move toward universal health insurance, via both new subsidies and increased outreach and enrollment assistance, it is vital that the promise of affordable insurance not be undercut by hidden consequences for enrollees. The Coalition believes that Medicaid Estate Recovery from over-55 enrollees who do not receive LTSS services violates the core promise of the ACA to provide "affordable care" to those who seek it. The
2021 MACPAC report indicates that Medicaid Estate Recovery disproportionately targets less-wealthy enrollees and yields paltry revenue to the states.
The Coalition's commitment to extending access to affordable, quality health care for all New Jerseyans is embodied in our work to advance Cover All Kids legislation, focused on enrolling uninsured New Jersey children in NJ FamilyCare. We regard eliminating the threat of Medicaid Estate Recovery as part and parcel with the effort to extend access, awareness, and trust in NJ FamilyCare to all New Jerseyans who would benefit from enrollment. We trust that you share this goal, and we hope to meet with you at your convenience to discuss how we may best help advance it.
Dear Senator Cryan:
Thank you for sponsoring S3759, limiting the authority of DHS to impose liens and seek recovery from Medicaid recipients' estates after death to enrollees who obtain LTSS, as well as limiting the scope of recovery. On behalf of the NJ for Health Care Coalition, I am writing to request a meeting to discuss plans to get this vital bill enacted.
At a time when new state and federal resources are being committed to move toward universal health insurance, via both new subsidies and increased outreach and enrollment assistance, it is vital that the promise of affordable insurance not be undercut by hidden consequences for enrollees. The Coalition believes that Medicaid Estate Recovery from over-55 enrollees who do not receive LTSS services violates the core promise of the ACA to provide "affordable care" to those who seek it. The
2021 MACPAC report indicates that Medicaid Estate Recovery disproportionately targets less-wealthy enrollees and yields paltry revenue to the states.
The Coalition's commitment to extending access to affordable, quality health care for all New Jerseyans is embodied in our work to advance Cover All Kids legislation, focused on enrolling uninsured New Jersey children in NJ FamilyCare. We regard eliminating the threat of Medicaid Estate Recovery as part and parcel with the effort to extend access, awareness, and trust in NJ FamilyCare to all New Jerseyans who would benefit from enrollment. We trust that you share this goal, and we hope to meet with you at your convenience to discuss how we may best help advance it.
--
Note to Laura w/ link to nuanced NJ FamilyCare stats, 9/25/23
Laura, re
S3759: text of the
Bill Statement below. And below that, the count of NJ Medicaid enrollees over age 55: 193,000. Stats
here. Only about 10-20k of those would be in long-term care.
This bill amends the law governing the State’s Medicaid estate 35 recovery program and limits the authority of the Division of 36 Medical Assistance and Health Services (DMAHS) in the 37 Department of Human Services to impose a lien and seek recovery 38 from a Medicaid recipient’s estate after death. This bill is designed 39 to allow Medicaid recipients to preserve certain assets and savings 40 for their heirs, while also meeting the minimum federal 41 requirements for the State’s Medicaid estate recovery program 42 pursuant to the “Omnibus Budget Reconciliation Act of 1993,” 43 Pub.L.103-66. 44 Currently, New Jersey’s Medicaid estate recovery program pursues 45 recovery of payments provided through the Medicaid program for all 46 services received on or after the age of 55. Under this bill, the 47 DMAHS would be limited to pursuing recovery for costs associated 48 with nursing facility services, home and community-based services, S3759 CRYAN 4 1 and hospital and prescription drug services provided concurrently 2 with nursing facility or home and community-based services 3 received on or after the age of 55. 4 Additionally, this bill would restrict the definition of “estate” to 5 real and personal property and other assets included in the Medicaid 6 recipient's estate as defined in N.J.S.3B:1-1. In doing so, recovery 7 would be limited to all property and assets that pass from a deceased 8 person to his or her heirs under probate law. Currently, the New 9 Jersey Medicaid estate recovery program utilizes an expanded 10 definition of “estate” which enables DMAHS to also recover from 11 some or all property that bypasses probate, such as life insurance, 12 pension benefits, retirement accounts, and jointly owned real estate 13 and accounts. 14 Finally, the bill makes technical corrections by revising the use of 15 pronouns and removing certain statutory language that no longer 16 applies under current law
re dual eligiblity:
1. MSP beneficiaries in NJ not subject to estate recovery
https://www.nj.gov/humanservices/dmahs/clients/The_NJ_Medicaid_Program_and_Estate_Recovery_What_You_Should_Know.pdf
2, The morass of dual eligibility, in and out of MSPs
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf
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