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.