VIA ELECTRONIC SUBMISSION
Centers for Medicare & Medicaid Services Department of Health and Human Services
Attention: [email protected]
Conversion of Net Income Standards to Equivalent Modified Adjusted Gross Income Standards and Solicitation of Public Input
Dear Sir/Madam:
The National Health Law Program (NHeLP) protects and advances the health rights of low income and underserved individuals. The oldest non-profit of its kind, NHeLP advocates, educates and litigates at the federal and state levels. We appreciate the opportunity to provide CMS with comments on the proposed guidance for the conversion of net income standards to modified adjusted gross income (?MAGI?) standards.
NHeLP commends CMS? thoughtful effort to identify the best method to convert current income limits to MAGI equivalents. We particularly appreciate CMS? solicitation of public input to include stakeholder feedback. NHeLP believes stakeholder input will be critical to designing a good policy because of the incredible variation in state Medicaid categories, income limit levels, population demographics, and deduction, income counting and disregard methodologies. Our comments below emphasize the importance of minimizing breaks in enrollment and continuity of care for enrolled individuals. We believe this represents the most efficient approach to setting conversion standards and matches the legal requirements and intent of the ACA.
A. General Framework
While we would welcome a policy that requires maintaining the eligibility of every individual through the conversion to MAGI and we believe the law would support such an interpretation, we realize the statute does not require and CMS is not currently considering such a policy. CMS could easily set such a methodology (simply calculating the equivalent MAGI threshold for the individual with highest current deductions or one at the 95th percentile if CMS wanted to avoid the outliers) to maximize eligibility and continuity. We recognize it might increase enrollment levels and potentially lessen state enhanced matching funds.
Assuming CMS does not pursue a method to maintain individual eligibility, we support CMS? intent to ensure aggregate equivalence. We believe this approach meets the minimum requirements of the ACA. To comply with statutory language, we make two broad recommendations for the conversion methodology.
First, if the conversion methodology resulted in fewer individuals enrolled, it would violate the language, intent and structure of the ACA. We therefore recommend that CMS require that conversions never have the effect of reducing the aggregate eligible population, regardless of the validity of the method. Another way of saying this is that the ?Same Number Net and Gross Method? (discussed below) should form a minimum threshold for every state.
Second, we recommend that CMS build some additional enrollment into the conversion methodology. The conversion methodology should result in an increased number of potentially eligible individuals. This is critical because, while we can be sure that states will identify and disenroll all individuals who become ineligible based on the conversion (losers), it is equally clear that states will not successfully identify and enroll all individuals who are potentially eligible (winners). Some individuals may never come into the system, others may fail in the enrollment process, and others may be misidentified and enrolled into the wrong program (for example, if their categorical eligibility is not identified). In short, while all the conversion losers will lose, only a fraction of the winners will win. Assuming that no state will successfully enroll all the potential winners, any mathematically accurate MAGI-conversion method will necessarily result in an aggregate reduction in enrollment?an as-applied violation of the statutory language and intent. We note this problem will be especially grave for individuals in states that do not implement a Medicaid Expansion. Potential winners may already think they are not categorically eligible without the expansion and never bother to apply. Worse, many individuals who lose Medicaid eligibility would not qualify for subsidies on the exchange and so end up completely uninsured.
Therefore, we recommend that the selected methodology build in an enrollment cushion (and CMS might consider the need to make that additional enrollment even higher in states that don?t adopt a Medicaid Expansion). This recommendation is entirely consistent with the intent and letter of the ACA. The language of the statute does not command CMS to peg the conversion to the exact same level. Instead, it commands CMS to set conversion standards ?that are not less than the effective income eligibility levels? currently in place. ACA § 2002(a) adding new Social Security Act § 1902(e)(14) (emphasis added). This statutory language clearly supports setting the standards above the current standards ? and we believe the statute was written this way in recognizing that converting current standards faithfully and fairly might require raising eligibility levels.
We recognize that, from the point of view of individuals, there will be winners and losers under every methodology except one that protects all individuals. (We note that this methodology, too, would be consistent with the requirement for converted MAGI income levels ?that are not less than the effective income eligibility levels.?) However, there is nothing in the statute requiring CMS to create equal numbers of winners and losers. Continuity of care, the needs of this low-income population, administrative simplicity, and basic fairness all mitigate in favor of minimizing losers. These considerations support our suggestion to guarantee at least equal eligibility numbers and provide for additional eligibility. This is entirely consistent with the legal intent and language of the statute.
Finally, we note that The Supreme Court?s decision regarding the Medicaid Expansion decision has potential to significantly change the impact of the conversion standard in states that forego the expansion. In such states, many individuals made ineligible by the conversion would lose all eligibility for coverage. We believe CMS should consider implementing a two-tiered system whereby non-expansion states would use a conversion methodology that more heavily favors maintaining current eligibility. Otherwise, the outcome of the conversion could prove catastrophic in non-expansion states.
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