State Medicaid Reforms Place More Responsibility on Patients

A small number of West Virginia's Medicaid-eligible population has enrolled in a new pilot program that has drawn criticism from mental health advocates for placing unreasonable demands on people with mental illness.

The pilot program, called Mountain Health Choices, operates in three counties and is designed to encourage healthy lifestyles. Enrollees are eligible to receive enhanced benefits in exchange for signing contracts that pledge they will pursue healthy behaviors, such as regular physician visits and use of necessary medications. The program offers options to help beneficiaries maintain a healthy lifestyle through weight management, cardiac rehabilitation, and nutrition-education programs.

The goal of the program is to improve state residents' overall health and reduce Medicaid's long-term costs. However, among 2,236 eligible residents, only 64 adults and 216 children had enrolled by July, according to the state Medicaid agency.

State Medicaid officials expect that as more beneficiaries learn about the program, the number of residents enrolled will increase.

The new program was made possible by the Deficit Reduction Act of 2005 (DRA), which President Bush signed into law early last year. The law gives state Medicaid officials greater latitude to amend their programs to increase cost sharing and premiums or to reduce benefits. Prior to the DRA, states seeking such sweeping alterations to their programs had to go through a public review process and be approved for a waiver by the secretary of Health and Human Services.

Several states that amended their programs under the DRA, such as West Virginia, Kentucky, and Florida, have come under criticism from mental health advocates for changes that placed a heavier program compliance burden on beneficiaries with mental illness than they are often able to meet. For example, continued access to Medicaid mental health and substance abuse benefits under West Virginia's enhanced package is based on compliance factors such as taking medication as directed and keeping all medical appointments. Beneficiaries with mental health and substance abuse problems may have difficulty complying with such requirements (Psychiatric News, June 2, 2006).

West Virginia Medicaid officials used their authority under the DRA to implement a Medicaid amendment in 2006 to create an “enhanced” program. The program's redesign included a choice of two benefit packages: a basic plan based on the current Medicaid service package and an enhanced plan for those who sign and adhere to a compliance agreement, which includes benefits not traditionally offered under Medicaid.

In a major change from the standard Medicaid program, the new plan limits access to chemical dependency and mental health services to those who choose the enhanced package. Access to those services is based on compliance with a“ member agreement,” which requires actions such as taking medication as directed and keeping all medical appointments. Beneficiaries who do not adhere to the agreement are rolled back into the basic plan for 12 months, after which they can reapply for enhanced benefits.

More Access to MH Care Offered

Mental health advocates said placing the onus on beneficiaries with mental illness to manage their health care can be “unrealistic” in light of the seriousness of some of the illnesses from which they suffer and symptoms that can make it difficult for them to comply (Psychiatric News, September 1, 2006).

The limited enrollment in the new Medicaid program has led critics to say the first-in-the-nation approach will not meet the state's goals in improving overall health and reducing the long-term costs of Medicaid.

However, state Medicaid officials said they are satisfied with the progress of the program and plan to continue gradually rolling it out across the state. As more Medicaid recipients learn more about the enhanced benefits beyond the basic Medicaid plan—such as skilled nursing care—according to state officials, more are likely to enroll.

In West Virginia, about 288,000 residents are enrolled in Medicaid, which is the largest single item in the state budget, at $2.1 billion in state and federal funds.

Alabama Changes Medicaid Plan

The Centers for Medicare and Medicaid Services approved another state's Medicaid DRA amendment in July. Alabama is the first state to receive federal approval to allow self-directed personal assistance services as a feature of its Medicaid plan, eliminating the need for repeated waiver requests.

The new benefit will allow Alabama Medicaid enrollees to direct their personal care, homemaker, unskilled respite, and companion services. Alabama will allow participants to hire “legally liable” relatives to provide care and to use the funds budgeted for those services to pay for items that increase their independence or substitute for paid allied-health assistance. The state will also permit participants to receive some cash from the Medicaid program so that goods and professional services can be purchased directly.

“Alabama is the first to benefit from the federal law giving states an easier way to deliver better care by allowing Medicaid beneficiaries to have more control over the care they receive,” said Mike Leavitt, secretary of the Department of Health and Human Services.

When beneficiaries direct their own care, federal officials said, research has found fewer unnecessary institutional placements, higher levels of beneficiary satisfaction, fewer unmet needs, less worker turnover, and a more efficient use of community services and supports.

Federal officials said several other states have expressed an interest in providing a similar option for their Medicaid populations.

Information on West Virginia's and Alabama's Medicaid programs is posted at<www.statehealthfacts.org/r/mfs.jsp>.▪