Here is a koan for Balloon Juice:
If you do not know you are insured, are you insured?
Maine is in the process of expanding Medicaid. The new Governor-Elect, Janet Mills (D), has promised to expand Medicaid on her first day in office. She wants to make the coverage retroactive to July 2, 2018.
A Maine judge has ordered the current Maine governor to expand Medicaid with claims payment retroactive to July 2, 2018.
In most states, Medicaid has an individualized retroactive eligibility processes. Someone who is uninsured will interact with the medical system. The medical service provider will ask several standardized questions to determine if the uninsured patient is highly likely to be eligible for Medicaid. If they determine that the patient is likely to be eligible, they can file a claim and an eligibility determination. If the beneficiary is deemed eligible, some state Medicaid programs will pay both the index claim that initiated the eligibility determination process and claims in the three previous months if the benefeciary would have been eligible for Medicaid if they had applied.
The trigger event is a claim which means the trigger is an encounter with the healthcare system. Most people who are eligible for Medicaid but not enrolled don’t interact with the healthcare system in any given month because most people don’t interact with the healthcare system in any given month.
Retrospective eligibility is a safety net for both the patient who will not be faced with crippling medical bills and healthcare providers who will get reasonably timely payment that is most likely more than the net present value of the minimal cash stream that uninsured and Medicaid eligible patients can and will pay.
Retrospective eligibility is highly likely to occur for either pregnancy or major medical events that require hospitalization. More common and lower cost events like a primary care physician visit are less likely to generate a claim and retrospective eligibility determination because that appointment will either not be made by the beneficiary or the appointment will be denied by the provider once they are sure that they won’t get paid.
Maine is going to be doing something very different. It will be declaring that all claims on or after July 2 will be eligible for retroactive payments if the beneficiary would have been Medicaid eligible (either for legacy or expansion).
Now this is where I have a question.
Will we see changes in provider and beneficiary behavior in anticipation of a Medicaid Expansion? Did they increase the number of determination assessments that they submitted that would fail for legacy Medicaid but pass for Medicaid Expansion in July, August and September? Are providers pre-emptively opening up appointment blocks for people who are uninsured but Medicaid Expansion eligible? Are people who are Medicaid Expansion eligible making appointments in anticipation of retroactive eligibility?
How do people behave when they are covered if they are not sure that they are covered?
I don’t know but I think that this is one hell of a question.
On the Road and In Your Backyard
SRW1
Quantum mechanics is a hell of a way to run a health care system. But then that makes it only two was to spin it.
Ken
This sounds a little like the pre-ACA status, where people thought they were covered until they tried to file a claim.
bbleh
Well, it’s kind of axiomatic that people act on the basis of the beliefs they have. And it’s so evident in practice that it might as well be axiomatic that (1) almost all people’s beliefs are materially both incorrect and subject to uncertainty and (2) people are mostly not very good at decisions under material uncertainty, e.g., they substitute imperfect heuristics for sound reasoning. These apply just as well to people who believe they ARE covered as well as to those who believe they’re not or aren’t sure. (For example: how many people know the details of their coverage? How many people are aware of the ERAP problem? How many people know which area hospitals are in-network and out? Etc.)
I would guess that the answer to the question is a 2-D continuum, over both actual coverage and sophistication regarding medical decision-making, and that the behavior of many well-covered people resembles that of people who aren’t covered (or don’t believe they are) in that they act impulsively and irrationally, e.g. by neglecting wellness care, delaying seeking care, using ERs for everything when they do seek care, not checking to see what may be covered or not before selecting treatment, etc. etc.
Somebody needs to do a thesis, including lots of empirical research.
David Anderson
@bbleh: yep this is a cool dissertation
Agorabum
It has always baffled me that hospitals and medical professionals, especially those who provide coverage in rural areas, haven’t done more to push the Medicaid expansion.
As for the greater question, I’d expect that most patients take a “I’ll believe it when I see it” other than those who are both politically savvy and desperate (a small subset), while hospitals will be maximizing revenue in a much more thoughtful way.