Rearranging the Deck Chairs on the Titanic: Floridians Would Lose Coverage Under Both U.S. Senate and House Health Care Bills
The U.S. Senate bill to repeal and replace the Affordable Care Act (ACA), like its House-passed counterpart, would do irreparable damage to the Medicaid program and the millions of Floridians relying on it as their lifeline, including children, people with disabilities and elderly residents.
The Senate’s Better Care Reconciliation Act (BCRA) would result in an additional 22 million Americans losing health care coverage compared to the current law. According to the Congressional Budget Office, the Senate bill would also cut Medicaid by $772 billion over the next decade by eliminating Medicaid expansion and converting Medicaid into a per capita cap program.[1]
There are a number of ways the Senate version of ACA repeal proposal would do harm to Floridians on Medicaid.
The bill would effectively end the support for insurance coverage that fueled the historic coverage gains achieved under the ACA, while residents would see skyrocketing health insurance premiums.
Even though Florida did not expand Medicaid under the ACA, it benefitted from a reduction in its rate and number of uninsured residents, from 21.3 percent (3.94 million) in 2010 to 13.3 percent (2.6 million) in 2015.[2]This reduction is primarily the result of the ACA’s health insurance coverage provisions, including marketplace subsidies. The BCRA would sharply cut the ACA’s tax credits and subsides in 2020, making access to health insurance coverage prohibitively expensive for Floridians struggling to make ends meet.
Florida led all states in the number of individuals enrolled in the health insurance marketplace. Of 1.76 million Floridians who enrolled between November 2016 and the end of January 2017, 90 percent received federal tax credits for the coverage and 72 percent had their insurance coverage subsidized by the federal government.[3] The Senate bill not only cuts these tax credits, it also allows increases in health insurance premiums. Premiums for a silver coverage plan are projected to increase by 69 percent in Florida ($237 under BCRA compared with ACA’s $140 per month)[4], making health insurance coverage unaffordable for low-income families.
Because the Senate bill allows differential rate increases by the age of the insured, many older people would see their premiums rise by thousands of dollars.[5] Current cost-sharing assistance for deductibles and co-payments would be eliminated, making access to care unaffordable for many who are currently insured.
Insurers would be allowed to drop essential health care coverage such as maternity care and mental health and substance abuse treatment.
Prior to implementation of the essential benefits requirement under the ACA, three out of four health plans in the non-group market did not cover delivery and inpatient care. A significant percentage also excluded mental health and substance abuse treatment.[6] Allowing plans to drop essential benefits would once again exclude people with pre-existing conditions from accessing vital life-sustaining services. In states where essential health benefits are eliminated or weakened, the choice for people seeking these crucial life-saving services would be tough: either pay “substantial out-of-pocket costs or forgo the services.”[7]
The Senate bill, like the House legislation, cuts and caps federal Medicaid funding.
The Senate bill envisions a per capita cap system that would make an even deeper cut to Medicaid than the House’s bill, the American Health Care Act (AHCA) by slowing the growth rate of federal Medicaid spending compared with general inflation or actual Medicaid costs per beneficiary starting in 2025, effectively shifting the costs and risks of care to the state. Florida’s budget would take be impacted, as more than four million low-income Floridians rely on Medicaid as a lifeline, especially children, people with disabilities and senior residents.
The per-enrollee cost of care for the elderly and people with disabilities is more than double their share of representation in Florida’s Medicaid program.[8] These cuts and caps would also reduce already limited resources to fight Zika, the opioid epidemic and public health crises borne of natural disasters.
Research reveals that under a per capita cap system, states like Florida with a growing senior population are likely to exceed their capped federal Medicaid budget, because the cost of care for older residents is five times higher than that for younger individuals. The higher cost, compounded by high numbers of relocating seniors, would require the state to offset federal funding reductions by cutting spending in other parts of the state budget, such as education or public safety, or making much deeper cuts to Medicaid eligibility, benefit levels and/or provider rate payments.
More than half of Florida’s Medicaid budget (61 percent for FY 2017-18) comes from the federal government. Losing a growing share of this funding — which is what would happen under a per capita cap system—would be a huge blow to the state budget. These reductions are further expected to affect the financial stability of hospitals and health professional staffing needs.
A further cut to Medicaid eligibility or provider rates would result in thousands of low-income Floridians losing Medicaid coverage, including children, seniors and people with disabilities, while decreased reimbursement rates is expected to result in many providers declining to accept Medicaid patients.
Both bills envision work requirements for Medicaid recipients.
The BCRA, like its House counterpart, also envisions work requirements in the Medicaid program. Currently, 73 percent of Florida’s Medicaid working-age participants live in working families and 52 percent are employed, according to the Kaiser Family Foundation.[9] These families are on Medicaid for the very clear reason that their job is insufficient to afford the basic cost of living in Florida, let alone offer them health insurance benefits.
Those who are not working have legitimate barriers that would limit their ability to work, including illness or disability, retirement or attendance at school.[10] The work requirement under the Senate bill introduces an unnecessary and prohibitive requirement that could cause people to forgo the essential health insurance coverage they need for survival.
Both the House and Senate bills take critical health care away from families and individuals with the least means to fund billions of tax cuts for the wealthiest.
As highlighted by a recent Center on Budget and Policy Priorities[11] report, the Senate’s bill is no different in the harm it will cause to families already struggling to meet basic needs. Across the country, under both bills, millions will lose health coverage.
It’s not too late for a course correction. We urge senators to slow down and take the time necessary to build on the progress made under the ACA and develop a proposal that will enhance Floridians’ access to quality, affordable health care. Such a policy would benefit the health and economic security of all Floridians.
Notes
[1] The Congressional Budget Office (CBO). 2017. H.R. 1628, Better Care Reconciliation Act of 2017. Accesses via https://www.cbo.gov/publication/52849
[2] U.S Census Bureau. 2010 and 2015 American Community Survey, 1-Year Estimates, Table S2701
[3] State Health Facts: 2017 Marketplace Plan Selection with Financial Assistance, Kaiser Family Foundation, 2017. Accessed via: http://www.kff.org/health-reform/state-indicator/2017-marketplace-plan-selections-by-financial-assistance- status/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
[4] Claxton, Gary et al. 2017. Premiums Under the Senate Better Care Reconciliation Act. Kaiser Family Foundation. Appendix Table 2. http://files.kff.org/attachment/Issue-Brief-Premiums-under-the-Senate-Better-Care-Reconciliation-Act
[5] Aaron-Dine, A., Straw, T., Senate Bill Still Cuts Tax Credits, Increases Premiums and Deductibles for Marketplace Consumers, Center on Budget and Policy Priorities, 2017. Accessed via: http://www.cbpp.org/research/health/senate-bill-still-cuts-tax-credits-increases-premiums-and-deductibles-for
[6] Claxton, G., Politz, K., Semanskee, S. Levitt, L., Would States Eliminate Key Benefits if AHCA Waivers are Enacted? p. 2, Kaiser Family Foundation, 2017. Accessed via: http://www.kff.org/health-reform/issue-brief/would-states-eliminate-key-benefits-if-ahca-waivers-are-enacted/
[7] Supra note at 1
[8] Dadi, Esubalew. 2017. American Health Care Act Threatens Access to Coverage for Millions of Seniors and Peoples with Disabilities. Florida Policy Institute.
[9] Garfield, Rachel et al. 2017. Understanding the Intersection of Medicaid and Work. Table 1. Kaiser Family Foundation http://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/
[10] Ibid
[11] Center on Budget and Policy Priorities. 2017. Tracking Reports About the Emerging Senate Bill to Repeal the Affordable Care Act. http://www.cbpp.org/research/health/tracking-reports-about-the-emerging-senate-bill-to-repeal-the-affordable-care-act
Re-employment Assistance (RA)
Department of Children and Families (DCF) Multi-Program Policies
Supplemental Nutrition Assistance Program (SNAP)
Medicaid
Child Nutrition Programs
Temporary Assistance for Needy Families (TANF)
Re-employment Assistance (RA)
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.
Reemployment Assistance weeks reverted to 12 effective January 1, 2022. 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 downturn in unemployment, the maximum number of weeks for RA reverted to 12 effective January 1, 2022.
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.
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.
DEO announces extended benefits. DEO announced implementation of Extended Benefits (EB).
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 12/30/2020, go here.
For DEO’s latest claims data, go here.
Department of Children and Families (DCF) Multi-Program Policies
DCF opens offices. DCF has reopened its brick-and-mortar storefronts, which were previously closed due to coronavirus.
DCF adds call center numbers. DCF has added a call center number for Monday through Friday, from 7 a.m. to 6 p.m. Call center numbers now include 850-300-4323, 866-762-2237, or TTY 1-800-955-8771.
Certification periods extended by 6 months only through August 2020. Certification periods for cash, food and medical assistance were extended by 6 months for individuals and families scheduled to recertify in April through August 2020. FNS’ approval of the SNAP extension for August is here. However, effective September 1, 2020, SNAP, TANF and Medicaid recertifications have been reinstated, although DCF says that no one will lose Medicaid due to recertification.
DCF allows phone interviews. Phone interviews are now being used for TANF cash and SNAP food assistance.
Mandatory work requirements suspended only through May 2021. Under a directive from Governor DeSantis to waive work requirements for safety net programs, DCF waived work requirements for individuals participating in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) through May 2021. To do this, DCF explains that it partnered with the Department of Economic Opportunity to apply “good cause” statewide for TANF and SNAP recipients who would otherwise be subject to participation in mandatory work requirements as a condition of receiving those benefits. Through May 2021, persons who were sanctioned in the past due to work requirements will be able to reapply and participate in SNAP or TANF again.
Work requirements were reinstated effective June 1, 2021.
Supplemental Nutrition Assistance Program (SNAP)
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.
The SNAP benefits increase by 15 percent ended in October 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.
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.
Medicaid
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 January 16, 2022.
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.
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.
Child Nutrition Programs
School children in distance learning still eligible for free or reduced cost meals. Students in distance learning for 2020-21 can still receive school meals through the National School Lunch Program if they are eligible. The student or parent/guardian may pick up meals at the school but should contact their school for more information.
For a list of current child nutrition program waivers for Florida from USDA, go here.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Congress allows increased fruit and vegetable benefits. At present, WIC provides $9 for children and $11 for women monthly for fruits and vegetables. The American Rescue Plan Act makes funding available for a four-month increase in the benefit of up to $35 monthly, if a state chooses to do so.
DOH attains waiver allowing remote issuance: Department of Health (DOH) obtained a waiver of the requirement that participants pick up their EBT cards in person at recertification or during nutritional education appointments.
WIC participants allowed to substitute certain food. Under a waiver from USDA, WIC participants in Florida are allowed to substitute milk of any available fat content and whole wheat or whole grain bread in package sizes up to 24 oz. when 16 oz. packages are unavailable.
USDA waived physical presence requirements: Although the scope and logistics are unclear at this time, USDA has given DOH permission to waive the requirement that persons be physically present at each certification or recertification determination in order to determine eligibility under the program through May 31, 2020.
USDA extends certification periods through May 31, 2020, for some participants.
For a list of current WIC waivers for Florida from USDA, go here.
Temporary Assistance for Needy Families (TANF)
HHS provides guidance. HHS has issued guidance on the flexibilities in TANF to respond to COVID-19.
