Inside ARHOME, the state’s new vision for Medicaid expansion

A NEW PLAN: (From left) DHS Director Cindy Gillespie, Rep. Michelle Gray, Governor Hutchinson and Sen. Missy Irvin at Monday's press conference. (Credit: Benjamin Hardy)

The state’s Medicaid expansion program would get a makeover under a new proposal described in a bill filed Monday by Sen. Missy Irvin (R-Mountain View) and Rep. Michelle Gray (R-Melbourne). The bill was approved by a Senate committee on Thursday and will now go to the Senate.

The proposal, developed along with lawmakers by the state’s Department of Human Services, would replace the state’s current program, known as Arkansas Works, with a new program dubbed Arkansas Health and Opportunity for Me (ARHOME). Arkansas Works now provides health insurance for more than 310,000 low-income Arkansans.

ARHOME does not include the state’s controversial Medicaid “work requirements” policy, replacing it with “incentives” to encourage work, education and related activities. ARHOME would also feature additional costs imposed on beneficiaries; incentives for wellness programs; mechanisms to contain the cost growth of private plans used for the Medicaid expansion and measure health outcomes; and new initiatives for rural health, maternal and infant health, behavioral health and certain at-risk populations.

Currently, most Arkansas Works beneficiaries are covered by private health insurance plans, paid for by Medicaid. ARHOME proposes moving some of those beneficiaries to the traditional, fee-for-service Medicaid program if they do not participate in incentives programs.

“No one loses health care benefits,” Governor Hutchinson said at a press conference Monday unveiling the legislation. “But there are incentives … to make sure that you improve job skills, improve your opportunities to work … to encourage that kind of behavior and that kind of progress in life.”

Many key pieces of the proposal remain vague. The bill does not outline precisely what beneficiaries would be required to do in order to earn the incentives, or how those obligations would be tracked or verified.

DHS Secretary Cindy Gillespie said that the bill sketched out a general framework. If the bill is passed, DHS will continue to work with lawmakers on finalizing the details. “You start with a framework, and then you begin to put meat on that framework,” she said.

If the legislature approves the ARHOME proposal, it will still require federal approval from the Biden administration for a waiver of Medicaid rules. The current waiver for Arkansas Works expires at the end of this year. DHS is aiming to send a request for a new waiver this summer.

Gray said the need for federal approval is part of why details in the legislation remain hazy. “We don’t know what the Biden administration will allow,” she said. “We’re trying to put the framework out there but not be so specific that it doesn’t allow DHS some flexibility.” Despite extensive discussions between lawmakers and DHS, Gray said, “We did not put anything in the bill that specifies what the incentives will look like just because we want some leeway with the waiver.”

Here are some of the key components included in the bill.

No work requirements 

The state’s Medicaid work requirements program, the first of its kind to be implemented anywhere in the nation, has been suspended since a federal judge halted the policy in March 2019. An appeal of that case is before the Supreme Court, but the Biden administration informed states last month that it will no longer allow Medicaid work requirements.

DHS will not request to continue the work requirements program when it applies for a new waiver, but Arkansas Attorney General Leslie Rutledge has nonetheless argued that the Supreme Court should rule on the work requirements case. The Biden administration contends that the Court should cancel oral arguments, scheduled for later this month, because the administration will not authorize work requirements in any event, essentially rendering the case moot.

If the case does move forward, it won’t impact the state’s policies in the near term. But a favorable ruling from the Supreme Court could ease the path for a future presidential administration to grant work requirements.

The case still matters, Hutchinson said. “It’s important to us,” he said. “Four years from now, we might have a Republican administration, and they can look at some of these … requirements again.”

The ARHOME bill states that Arkansas will seek to reinstate work requirements in that event: “The Governor shall request a waiver under relevant federal law and regulations for a work requirement as a condition of maintaining coverage in the Arkansas Medicaid Program as soon as practical if the federal law or regulations change.”

Work “incentive”

The ARHOME proposal attempts to incentivize beneficiaries to participate in work, education or related activities by using private plans as a reward. This component of the plan would represent a new twist on the state’s unique version of Medicaid expansion, which has been in place since 2014. Instead of expanding coverage using the state’s traditional Medicaid program, which pays medical providers directly for services (“fee-for-service”), the state got federal approval to use Medicaid expansion funds to purchase private health insurance plans for eligible low-income Arkansans. The plans are purchased on the Arkansas Health Insurance Marketplace from companies such as Arkansas Blue Cross and Blue Shield and Centene (which sells insurance in Arkansas under the names Ambetter and QualChoice).

Unlike under the old work requirements program, no one would lose coverage altogether if they did not participate in ARHOME’s incentives program. Instead, a person who failed to comply with the “economic independence initiative” could lose his or her private plan but would still be covered directly by the traditional, fee-for-service Medicaid program.

The theory behind the incentive is that beneficiaries would prefer a private plan because it could offer better access to more health care providers than Medicaid. Some providers do not accept patients on Medicaid because the program reimburses them at significantly lower rates than private insurance. According to the bill, one of the purposes of the proposal is that it “encourages personal responsibility for individuals to demonstrate that they value healthcare coverage and understand their roles and obligations in maintaining private insurance coverage.”

Another possible incentive for participating in the “economic independence initiative,” according to the bill, would be waiving premiums and other cost-sharing payments charged to certain beneficiaries.

The old work requirements program required certain beneficiaries to report their monthly activities. If people failed to report, they would be kicked out of the program, which led to 18,000 Arkansans losing their health coverage over the course of five months in 2018 and 2019.

It is not clear whether the new ARHOME incentives program would retain some sort of reporting mechanism, but DHS Secretary Gillespie said Monday, “We’re not planning on monthly reporting.” The bill does not specify how the program would operate, how DHS would verify that people were complying, or precisely what people would need to do in order to fulfill the incentive program’s obligations. Without offering specific details, Gillespie suggested Monday that beneficiaries might be able to achieve the incentive through participation in other aspects of the ARHOME program.

Gray said meeting the incentive to keep the private plan could even be as simple using the plan to see a doctor. One possibility that has been discussed, Gray said, is that “if they’re actively seeing their physician — well, they’re trying to better their health outcomes, that counts. So instead of saying you have to work so many hours … if you’re actively engaged, then you can stay in.” But these potential options for structuring the rules, she stressed, remain to be determined.

As under current policy, those deemed “medically frail” would be placed in the traditional Medicaid program and thus would not be in the “economic independence initiative” incentives program. And in a new initiative, people with serious mental illness or substance use disorder would be placed in a special category of coverage in the traditional Medicaid program, managed by an entity known as a risk-based provider organization. Otherwise, the bill states, “the economic independence initiative applies to all program participants.”

State officials have not provided specific projections on how many people would wind up in private plans versus in fee-for-service Medicaid.

“We hope that they stay [in private plans], we hope that none of them are moved over to fee-for-service, but we know that there will be some that fail to comply,” Hutchinson said. “We’ll just have to measure that day by day.”

While state officials are framing the ARHOME proposal as an incentive, the Biden administration may look skeptically on the request if the approach is seen as punitive, said Judy Solomon, a senior fellow with the Center on Budget and Policy Priorities. If the “assumption of the proposal is that fee-for-service Medicaid is worse coverage … that starts to make it more like a penalty,” she said. “Are there access issues? Are there providers that you see now that you wouldn’t be able to see [if moved to fee-for-service Medicaid]?”

Ultimately, these are empirical questions about how many providers are available for beneficiaries in fee-for-service Medicaid in Arkansas, Solomon said. But if beneficiaries suddenly lost the ability to keep their doctor or get the care they needed, moving people off of the private plans could be seen as “essentially taking coverage away, even though you’re still covered [by Medicaid].”

Solomon also expressed concern that the proposal’s bureaucratic complexity could create administrative hurdles and lead to confusion for beneficiaires. Medicaid beneficiaries often face challenges with “churn” — moving on and off coverage because of income changes. If beneficiaries are moving back and forth between private plans and fee-for-service Medicaid and have trouble navigating changes in coverage, that could create a sort of churn within the program, Solomon said.

Sen. Bob Ballinger (R-Ozark), a former opponent of Medicaid expansion who now anticipates supporting its continuation in some form, said that he was generally supportive of the DHS approach, but had questions about this aspect of the proposal. “When you get people switching back and forth, that’d be a problem,” Ballinger said. “It sounds like a lot of my constituents could be getting booted off, looking for ways to get back on, and get caught in the system.”


DHS Director Cindy Gillespie (at podium) and Rep. Michelle Gray. (Credit: Benjamin Hardy)

Premiums and co-pays for beneficiaries

The ARHOME plan could impose additional costs on beneficiaries. People who failed to pay would not lose coverage, but could be personally liable for a collectible debt.

The Medicaid expansion program covers adults who make less than 138 percent of the federal poverty level (an annual income of $17,774 for an individual or $36,570 for a family of four). The normal Medicaid rules do not allow states to charge premiums for this population; states can choose to charge small co-pays with limits set by the federal government, but providers cannot refuse service to people who make less than the federal poverty line for failure to pay.

Some states, including Arkansas, have used the waiver process to add additional cost-sharing elements, such as monthly premiums. Currently, Arkansas Works charges $13 monthly premiums and small co-pays capped at $60 total per quarter to people whose income is above the federal poverty line. No one loses coverage for failure to pay, but the state can attempt to recoup unpaid premiums by withholding state tax refunds. No cost-sharing is currently imposed on beneficiaries below the poverty line.

ARHOME would implement co-pays at all income levels, subject to federal limits on the amount charged for a given service. Beneficiaries on private plans who make more than the poverty level would be charged monthly premiums in addition to the co-pays. People below the poverty line, as well as beneficiaries covered by fee-for-service Medicaid, would be charged the co-pays but not the premiums. Beneficiaries who are medically frail, and those with serious mental illness or substance use disorder covered by the Medicaid risk-based provider organizations, would be exempt from premiums and co-pays.

Even if co-pays or premiums are small, they can have a negative impact on access to care for beneficiaries, said Joan Alker, the executive director of Georgetown University’s Center for Children and Families. “It’s very well established in the research literature that even minimal cost-sharing creates harmful barriers to needed care for low-income populations,” she said.

Under ARHOME, would providers be able to refuse service if beneficiaries failed to pay co-pays? Gillespie did not offer specific details but said that in practice, providers would be unlikely to do so for failure to pay the small co-pays.

ARHOME could potentially bump up the amount charged in premiums and the cap on total cost-sharing. As a matter of policy, the state currently sets a flat rate for premiums and the total amount that can be charged in co-pays. But under its current waiver — and under the proposed terms for ARHOME described in the bill — the state could charge the maximum that has generally been allowable for this population in Medicaid: 2% of family income for premiums and 5% of family income for the total cost-sharing (including both premiums and co-pays).

The bill does not specify the precise amounts that would be charged, but DHS spokeswoman Amy Webb confirmed that the plan for ARHOME is to charge the maximum allowable; Gray said that this was her understanding of the goal. For beneficiaries, this is where the details, still being ironed out, become crucial. Premiums set as high as 2% of family income could be much higher than the current flat rate of $13 per month. For example, a single mother with two kids who made $25,000 a year could theoretically be charged a premium of $41 per month. Individual co-pays, meanwhile, would remain small, but if the total cap on cost-sharing was 5% of family income, some beneficiaries could be charged significantly more in total than they are today.

While no one would lose coverage for failure to pay premiums, ARHOME could enact changes to the process for collecting debt on unpaid premiums. Currently, under Arkansas Works, if people fail to pay premiums, they owe a debt to the state. But the state’s current waiver agreement otherwise strictly limits what the state can do to collect: It is not allowed to report the debt to credit bureaus, refer the debt to collection agencies, or take legal action. The federal government has typically included such protections in waiver agreements with states regarding premiums.

The ARHOME bill would task insurance companies with collecting unpaid premiums, rather than the state. The state would not reimburse them for the uncollected amounts. It would establish a process under which “any unpaidliabilities” would be “solely the financial obligation of the individual” enrolled in the plan. The bill states that “failure by a program participant to meet the cost-sharing and premium payment requirement … may result in the accrual of a personal debt to the health insurer or provider.”

The process for insurance companies trying to collect premiums would have to be approved by the Biden administration as part of a waiver. Asked whether beneficiaries would receive protections from being referred to a collection agency or facing legal action under the ARHOME plan, Gillespie did not offer specific details. “That would be up to the [insurance company] because that debt is to the [insurance company],” she said.

But any new alterations to policies around cost-sharing would likely face close scrutiny by the Biden administration, said Andy Schneider, a research professor of the practice at Georgetown’s Center for Children and Families. “While we don’t yet know how the Biden Administration will view the use of premiums or copayments in [waiver demonstrations], I will be surprised if they are sympathetic to proposals to test such policies knowing that the foreseeable effect is to reduce coverage,” he said.

Wellness incentives

In addition to the work incentives program, ARHOME would also feature a “health improvement initiative,” which would aim to encourage participation in “health assessments and wellness programs, including fitness programs and smoking or tobacco cessation programs.” The wellness incentive would be developed by DHS or by the insurance companies, subject to approval by DHS, for those enrolled in private plans.

The incentives for participating in the wellness program could include waiving premiums or cost-sharing requirements. Less clear is whether the wellness incentive could be a substitute for the work incentive in terms of retaining a private plan. If someone participated in the “health improvement initiative” but failed to fulfill the obligations of the “economic independence initiative,” would that be sufficient to keep a private plan? Or would everyone that failed to keep up with the work incentive be moved to traditional Medicaid, even if they did the wellness program?

Lawmakers and state officials have hinted that some beneficiaries might be able to keep their private plan through wellness activities, support programs, or engagement with their medical providers, but the bill doesn’t specify what the rules would be.

The bill does not include details about how the wellness initiative would be administered, what beneficiaries would be required to do to earn the incentive or how participation would be verified.

Community bridge organizations

The ARHOME proposal aims to establish new initiatives for certain target populations within the Medicaid expansion population.

“Instead of treating every beneficiary the same, our thought process is: Can we actually work with these groups and different demographics and effect change for them?” Gray said.

Certain hospitals in the state, if approved by DHS, could establish “community bridge organizations” to connect beneficiaries with support services. The programs would be funded by Medicaid, with the federal government picking up 90% of the tab.

Birthing hospitals would offer services for mothers with high-risk pregnancies, including home visitations from pregnancy through the first 24 months of the child’s life.

Small rural hospitals would offer beds for people in crisis due to mental illness or substance use disorder; employ trained “coaches” to help beneficiaries get medical care and access other support services; screen and refer people for “health-related social needs”; and develop additional telemedicine capabilities.

Acute care hospitals would help to connect young adults at risk of poor health because of long-term poverty with community organizations that offer support services for health, employment and education. This program would target veterans, along with people who previously were were incarcerated, in foster care or in the custody of the Division of Youth Services.

A person who successfully completed an “economic independence initiative” through the community bridge organization could receive an additional benefit even after leaving the ARHOME program, according to the bill. If someone works more and winds up making more than 138% of the federal poverty level, that would make the person no longer eligible for the Medicaid expansion program. The bill states that if beneficiaries complete the work incentive program with a community bridge organization and get a bump in income that makes them no longer eligible, the program could then offer them financial assistance to help pay for a portion of the costs of new health insurance. Such assistance, which could apply to either insurance offered by a job or insurance purchased by the individual on the Marketplace, would be limited in amount and duration. It would be funded by Medicaid, Gray said, with the federal government picking up 90% of the tab.

“That provides an incentive for them to actually complete and make it through the program,” Gray said. People who get a job and find a way to get out of poverty are doing precisely what lawmakers hope they’ll do, she said.

Cost controls

ARHOME would enact certain policy changes to attempt to contain costs of the private plans. As part of its agreement with the federal government, the state must set a maximum per-person cost. Because health costs typically go up over time, that per-person maximum has an annual growth rate. Under ARHOME, the growth rate would be set lower, and insurance companies would be made to eat the cost if they failed to stay under the limits.

Insurance companies would also be required to set their rates under the assumption that the allowable cost-sharing imposed on beneficiaries is collected. Medicaid would not reimburse the insurance companies for uncollected cost-sharing.

Enrollment range for private plans

Currently, under Arkansas Works, new enrollees are initially placed in traditional fee-for-service Medicaid, pending placement in a private plan. Based on a screening survey, a small portion of them are deemed medically frail and put in the fee-for-service Medicaid program. The others can select which private plan they would like to enroll in, but those who fail to choose a plan themselves are auto-assigned a plan. As of September 2020, 84% of beneficiaries were in a private plan and 7% were designated as medically frail and receiving fee-for-service Medicaid coverage. The remaining 9% were new enrollees awaiting placement.

Under ARHOME, the department would set a predetermined monthly enrollment range for all of the private plans used in the program (the bill does not specify numbers for this range). If too many people were enrolled in private plans in a given month, the department would temporarily suspend auto-enrollment of new beneficiaries into those plans (this would only impact auto-assignment; people who actively picked a private plan would still be enrolled even if the overall enrollment maximum for private plans had been reached). Because the private plans are more expensive, maintaining a certain enrollment range could serve as one mechanism for the state to stay within its total budget targets.

However, the insurance companies would also have protections to help maintain enrollment above a certain level so that they would have a predictable population when they were setting their rates. If the percentage of people enrolled in private plans got too low, the department would take measures to increase total enrollment in those plans, potentially including temporarily slowing the number of people moved out of private plans and into fee-for-service Medicaid for failing to comply with the incentives programs. “In order to keep the [private plans] viable, there has to be a certain amount of people in that risk pool,” Gray said.

Health outcomes

The bill requires the insurance companies covering ARHOME beneficiaries to develop “an annual quality and performance improvement strategic plan,” to be approved by DHS. The companies must then issue periodic reports to DHS “regarding quality and performance metrics.”

The performance measurements would include primary care access and preventive care, maternal and perinatal health, care of acute and chronic conditions, and behavioral health care, according to a DHS PowerPoint presentation shared with lawmakers.

The bill would create a Health and Economic Outcomes Accountability panel, made up of certain members of the legislature, the executive branch and community members. The panel would make nonbinding recommendations to DHS regarding quality performance targets for the private plans. To establish those targets, Webb said that DHS officials are developing data sets to analyze “three dozen specific health quality measures.”

If DHS determines that one of the private plans used for ARHOME “has not met the quality and performance measurement targets,” then the department may apply financial sanctions, the bill states.

“We had several legislators that wanted more accountability for the [private plans],” Gray said. “So we don’t just feel like we’re throwing the money away. We’re trying to hold their feet to the fire. We’re trying to actually take this population and make them healthier.”

Benjamin Hardy contributed reporting.

This story is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.

The Arkansas Nonprofit News Network is an independent, nonpartisan news organization dedicated to producing journalism that matters to Arkansans. Our work is re-published by partner newsrooms across the state.