Medicaid Buy-In
Real Choice Starter Grant
Virginia Department of Medical
Assistance Services
Grant # 10-P-91410/3-01
Final Report
In April 2001, the Virginia Department of Medical Assistance Services (DMAS) applied for a $50,000 Real Choice Systems Change Grant to help Virginia facilitate a public and private collaboration to better assist Virginians with disabilities to live and participate in their communities. The Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration-HCFA) awarded DMAS this grant in July 2001 for the period of February 25, 2001 to December 31, 2001. At the end of this period, DMAS was to provide the Centers for Medicare and Medicaid Services (CMS) with a report detailing the financial use of the award and provide a narrative report describing the use of the grant funds. On December 10, 2001, CMS extended the grant period to end on December 31, 2002, and requested that DMAS provide an interim report describing the activities undertaken, outcomes achieved, consumer task force, use of funds, lessons learned and next steps, and advice to CMS.
DMAS used this award to study individuals with disabilities and how competitive employment interacts with their ability to maintain adequate heath insurance. There has been interest within the Commonwealth in expanding health coverage to Virginians with disabilities and DMAS staff had been researching employment related health barriers prior to the availability of the New Freedom Initiative grant. It is a common assumption that the fear of losing health insurance (Medicaid) might limit or discourage individuals with disabilities from seeking or increasing employment opportunities.
The Real Choice Systems Change Starter Grant provided an opportunity for DMAS to fund a survey that targeted specific Virginians with disabilities to gauge their healthcare and employment needs. These needs may include, but are not limited to, additional Medicaid coverage, the use of Personal Assistance Services (PAS), and transportation services. DMAS would not have been able to commission this survey without the Real Choice Systems Change Starter Grant.
Activities Undertaken
Based on the advice of technical expert Allen Jensen (George Washington University), individuals eligible for continued Medicaid coverage under Section 1619 (b) of the Social Security Act would have significant potential for participating in a buy-in program. Therefore, DMAS chose to survey Virginians eligible for 1619 (b) about their employment and health care coverage. There were several components of the survey which included their knowledge of 1619 (b), if they had coverage through an employer sponsored health plan, their need for PAS, and any transportation issues. DMAS contracted with the Virginia Commonwealth University (VCU) Survey Evaluation and Research Laboratory (SERL) to conduct a mail survey and coordinate a series of focus groups with individuals categorized as 1619(b) beneficiaries and identified by Social Security Administration (SSA) data tapes received by DMAS. The mail survey and focus groups took place between October 8, 2001 and February 28, 2002.
DMAS and the SERL designed a closed-ended survey around several areas of interest. The survey questions dealt with employment, demographics, health insurance coverage, Medicaid status, and knowledge of 1619 (b). Stakeholders at DMAS, other state agencies, the SERL, and technical experts in Oregon and Chicago reviewed the survey for content approval. DMAS then arranged for a pilot of individuals with disabilities to complete the survey prior to conducting the survey. This pre-survey testing generated survey design feedback concerning question wording and clarity, question order, and skip patterns. During this period, the SERL assisted DMAS with finalizing the survey, managing all aspects of the mail survey, conducting a two-wave mailing, data entry, data analysis, and generating a findings report. DMAS and the SERL intended to conduct focus groups of 8-10 participants beginning in December 2001. The focus groups were planned for different regions of the state: Richmond/Central, Tidewater/Southeast, Fredericksburg/Northern, Harrisonburg/Northwest, and Roanoke/Southwest. The SERL mailed invitation postcards and interested persons were invited to call SERL using a toll-free 1-800 number and were screened for potential participation by a SERL telephone interviewer. A $50 incentive was provided to each focus group participant. The SERL recommended an appropriate focus group facilitator who had an understanding of disability issues as well as content knowledge of Medicaid. The SERL arranged general administrative activities such as procuring meeting space, reminder phone calls to participants, and managing incentives. The Department of Rehabilitative Services (DRS) arranged transportation services to and from the focus groups for those participants who needed assistance. Each focus group was scheduled to last between 90 and 110 minutes and the SERL technical staff provided the audio-taping of the groups as well as a transcription and analysis. A focus group facilitator’s guide was developed in conjunction with overall planning activities. SERL coordinated the invitation and selection of focus group participants and coordinated the logistical aspects of the focus groups.
Outcomes Achieved
A total of 1,692 surveys were mailed to the 1619 (b) population. Bad addresses reduced the sample size to 1,430 people and a total of 730 surveys were completed, yielding a 51 percent response rate.
Responses for many of the question areas (demographic, health insurance, education, disability type, employment status, and knowledge of 1619 (b)) were very similar across all three Medicaid categories (Currently on Medicaid, No longer on Medicaid, Never on Medicaid). Differences were seen between respondents based on Medicaid status for questions related to hours worked per week, earnings, and limitation of work hours. Those currently on Medicaid tended to work fewer hours per week, earn less money, and limit their hours to a greater degree than their counterparts who had their Medicaid cancelled or had never been on Medicaid. Key concerns noted were a lack of reliable transportation, the need to save money for retirement (or other expenses), the need for prescription medications and personal assistant services.
This study used a population designated eligible by SSA as1619 (b) beneficiaries, so it was expected that they would be aware of 1619 (b). Of all the respondents, only 9%, or 65 people, had ever heard of 1619 (b). This fact is important, as this population will likely be one of the first eligible groups for a Medicaid buy-in. Thus, the implementation of a Medicaid buy-in program will require much promotion so that all eligible populations are aware of their options. The 1619(b) survey was a success in that it achieved a 51% response rate with the participants providing a wealth of information on demographics, employment and health insurance.A copy of this report, “Medicaid Work Incentive Survey: Report of Findings” is attached for further detailed information on this endeavor.
The first focus groups were held in December in Richmond and Virginia Beach.
The purpose of the focus groups was to discuss the design features that potential participants would like to see implemented in a Medicaid buy-in program. Information on employment experience and health insurance coverage was also solicited.
As expected, the focus group participants had a minimal knowledge of 1619 (b), therefore, the facilitators provided an overview of 1619 (b) and Medicaid programs. The meetings then resumed with the facilitator leading a discussion of how health insurance affects people with disabilities and their employment opportunities.
The general reaction to a potential Medicaid buy-in was positive. All the participants responded that they would be able and willing to work more hours. This additional work would lead to a higher income, which turned the discussion to earning limits and buy-in costs. The participants thought medical and/or disability related expenses should be excluded from the Medicaid buy-in if these items were necessary for employment. Other exclusions included transportation costs, all medications, personal assistants, dental and eye care, and medical equipment. With these cost exclusions the majority of groups said they would be willing to earn above the 1619 (b) income limit.
The discussions led to income levels and potential buy-in contributions. All participants felt there should be an increase to the allowed resource limits. Some did not want the inclusion of other family member’s earnings, such as an elderly parent or young adult. All participants wanted to increase their income and not be penalized for saving money. Participant contributions toward the cost of a Medicaid buy-in were acceptable. In general, the groups decided they would prefer a sliding fee schedule with premiums set as a percentage of income. Automatic reinstatement of Medicaid, or a grace period, was an important feature should they lose their job. There was disagreement about a minimum level of earning, but agreement on various co-payment amounts for prescriptions, doctor visits, and inpatient and outpatient care.
The meetings ended with a discussion of access to public benefits. In general, the groups did not utilize government benefits like transportation, vocational rehabilitation, or food stamps.
Scheduled focus groups for Northern, Northwestern, or Southwestern Virginia had to eventually be cancelled due to a lack of participant interest in these regions. Despite additional mailings and follow-up telephone calls, attempts were unsuccessful in eliciting sufficient participation that would result in reliable information. A copy of this report, "Medicaid Buy-In Focus Groups: Report of Findings from 1619(b) Eligible Individuals", is attached for further detailed information on this endeavor.
Use of Funds
The grant has been predominantly used for the SERL survey and focus groups. Attachment 1 lists grant fund expenditures (Standard Form 269A). Some of the survey component expenditures included: materials, postage, data entry, a toll-free telephone number, interviewers, respondent incentives ($3.00 per survey), project management staff, design costs, analysis and reporting. Costs associated with the focus groups included: notification, pre-notification, postage, a toll-free telephone number, development, design, research, planning, analysis, facilitator payment, reporting, participant incentive ($50.00 per participant), and project management. Additional grant funds were used for printing, conference attendance and meeting transportation for DMAS staff who were engaged in program development and research.
Lessons Learned
Information obtained from the 1619 (b) eligible population in Virginia demonstrated that few even recognized the 1619 (b) SSI status and were unlikely to take full advantage of the opportunity it affords. This work incentive is poorly understood by SSI beneficiaries in general and is vastly underutilized, in part, for this reason. Though possibly more so because of the fear of losing SSI status (e.g., the monthly check) that assures both a safety net (e.g., dependable albeit low income) and comprehensive health care coverage through Medicaid. There is also an underlying fear that too much in earnings may require them to owe SSA significant amounts in overpayments, reinforced by all-too-true stories of working SSI beneficiaries who got in trouble because of earnings. These issues have created a serious distrust and fear of taking the risk of employment, or of earning much in the way of income.
Any new work incentive, such as a Medicaid Buy-In, has to overcome the above issues. The 1619 (b) population will likely be one of the first eligible groups for a Medicaid Buy-In. Therefore, Federal and State entities will need to concentrate on education efforts to explain health coverage opportunities to Virginians will disabilities. Programs will have to be developed that provide a safety net, or an easy-back-on to Medicaid or other benefits. Trust will have to be developed and communication and education will be critical in order get individuals with disabilities to go work to their fullest capacity and seek their independence from a government system that has often been fragmented, contained built-in barriers to self-sufficiency, was not user-friendly and, at times, not very forgiving. There is a great deal to overcome, but our survey, focus groups, and many, many discussions with Virginians with disabilities demonstrate that there is a strong interest among these individuals in gaining autonomy. The development of employment related supports, like a Medicaid Buy-In, will be welcomed and staunchly supported by those who want to live the American dream.
Additional Activities Resulting from Primary Actions through the Starter Grant
In the Spring of 2002, members of the OneSource Project of the Northern Virginia Workforce Investment Board agreed to partner with the Virginia Department of Medical Assistance Services (DMAS) to address what appeared to be systemic problems resulting in underutilization of the work incentive available under Section 1619(b) of the Social Security Act. Based on evaluation of data by DMAS, there were fewer SSI recipients taking advantage of the opportunity to work or increase their earnings due to unfamiliarity, confusion, or concern about the impact of working on continued eligibility for SSI and/or their eligibility for Medicaid. As a result, DMAS proposed a pilot project in Northern Virginia to identify and address the problems or misunderstandings associated with 1619(b). DMAS chose to pilot in Northern Virginia because the number of 1619(b) beneficiaries was higher in this area and income levels also tend to be higher than elsewhere in the state, which increases the likelihood of beneficiaries reaching and being able to exceed the Social Security Administration’s state specific income threshold for Virginia.
Numerous meetings and discussions by the 1619(b) Pilot Project team enabled its members to conclude that a three-prong approach of training/educating/communicating with all stakeholders would be the best method to address. It was also decided to extend the pilot to urban, suburban and rural areas in order to maximize understanding of training needs that might be unique to the environment.
The first step in the training process would be to provide training modules, or refresher courses, to the agencies, Social Security Administration (SSA) and the Virginia Department of Social Services (DSS), that process the applications (1619(b) and Medicaid) before moving on to the next training component. DMAS contacted the federal and state agencies at a high level to gain support in addressing the problem from the top down. With the cooperation of regional and local SSA and DSS representatives, the 1619(b) Pilot first focused on retraining and educating the Northern Virginia staffs of SSA and DSS offices on the 1619(b) program as well as on the need to act carefully and expeditiously in processing individual applications. This training was accomplished by SSA and DSS during the summer/fall of 2002. DMAS staff was invited and participated in the 1619(b) component of training at local SSA offices in the Northern Virginia pilot area, which was included in the larger statewide Ticket to Work training that preceded the Ticket rollout in Virginia. DSS staff worked with the pilot team to develop a tutorial for use in retraining and it has also been added to the agency’s intranet to facilitate training of new staff or as a refresher.
The second phase of the pilot was to provide a 1619(b) training medium for the disability services providers, benefits professionals and consumer advocates who assist individuals with disabilities in their pursuit of greater independence. Toward this end, a 1619(b) Tutorial was developed to provide some basic information on this work incentive and how it operates so that these supporters can better aid their customers. Along with the tutorial, sample letters were developed that could be submitted to SSA and/or DSS, on behalf of working persons with disabilities who receive SSI, of the likelihood that the individual is eligible for continued SSI eligibility under 1619(b) and/or continued Medicaid coverage. Consumer and provider flyers with basic information about 1619(b) and Medicaid also were developed and included along with other training materials. Two train-the-trainer sessions entitled “Finding Answers to Section 1619(b) of the Social Security Act – Training for Disability Service Providers and Advocates” were scheduled in early December 2002 and invitations were widely disseminated throughout the disability community in Northern Virginia, resulting in over 80 registrants. Unfortunately, inclement weather on the morning of the sessions caused them to be poorly attended, necessitating rescheduling. These trainings were held again in February 2003 and were successful, based on the positive feedback received through an evaluation instrument provided to participants. Data compiled from the evaluations indicate that these “trainers” will share this valuable information with more than 654 additional disability services providers, benefits professionals and consumer advocates throughout the Northern Virginia pilot area (Fairfax County, Cities of Fairfax and Falls Church, Fauquier County, Prince William County, Manassas City and Manassas Park).
Upon completion of this second phase of training, efforts turned to informing consumers and their families. Educational materials are being finalized and it is expected that a variety of products and training modalities will be utilized to communicate this information to the public. Once this third phase is complete and its effectiveness can be evaluated, DMAS anticipates launching a statewide replication of this training and educational program.
Though not quantifiable at this time, members of the 1619(b) Pilot Project have received positive feedback from numerous sources regarding improvement in responsiveness of eligibility determinations for continuation of SSI and Medicaid under the 1619(b) program. DMAS expects this trend to continue and amplify as the materials and methods developed under the pilot and funded through the Starter Grant are further disseminated throughout Northern Virginia and eventually statewide.