Oct 20, 2016

Jack Regenbogen previously served as Senior Attorney at Colorado Center on Law and Policy.

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Health care problem warrants proper notice

by | Oct 20, 2016

When a Medicaid client receives an unexpected letter from the State of Colorado, it often marks the beginning of a trying and potentially life-altering ordeal. These letters, sometimes referred to as Notices of Action (NOAs), are mailed to clients when health care benefits are being reduced or terminated.

While these letters are a source of stress for their recipients, they are also a necessary component of administering the Medicaid program, since they provide clients with advance notice of the reduction, termination, or suspension of their benefits. The letters are intended to inform clients of any changes in their eligibility and to provide them with information about how to appeal the loss of their benefits if they believe the action is unjustified. The NOA is supposed to ensure that Medicaid clients are afforded their due-process rights guaranteed by U.S. Constitution.

In practice, NOAs are often vague and confusing. Most do not specify why benefits are being terminated or reduced, so Medicaid clients don’t always know whether they should challenge the decision. Furthermore, without proper notice, those who appeal may be unable to fully prepare their case.

Problems with notices can cause eligible Medicaid clients to unjustifiably lose their benefits. When this happens, under the best-case scenario, the client could re-apply for benefits, although the process of reapplying causes a delay in coverage and is more expensive to the state than simply maintaining coverage for those who are eligible. For clients who rely on daily services, the loss of Medicaid for even one day can result in serious health problems.

In light of these all-too-common notification issues, Colorado legislators formed an interim committee to address shortcomings in Medicaid client correspondence and NOAs. This Interim committee held three hearings over the summer, which included testimony from the Colorado Center on Law and Policy, the Colorado Cross-Disability Coalition (CCDC), and the Colorado Department of Health Care Policy and Financing.

During these hearings, CCLP and CCDC recommended several solutions that were developed into four bills, all of which were approved by the committee with bipartisan support. If the General Assembly passes these recommendations into law during the 2017 legislative session, these changes would significantly improve client correspondence and reduce the risk of clients losing coverage due to inadequate, confusing or uninformative letters.

Here is a brief summary of the bills approved by the interim committee and what they intend to accomplish:

  • Bill A would make improvements to an online appeals page designed to let clients submit additional documents that are relevant to their case. Due to technical limitations that affect Colorado’s administrative judicial website, some Medicaid clients have experienced difficulties providing adequate documentation for their appeal. In addition, some clients have reported that their right to receive continuing benefits pending the appeal has not been honored when they sought an appeal online. Bill A would allow Medicaid clients to submit additional documents relevant to their appeal and clarify that clients have the right to continuing benefits regardless of whether they appeal online or through other means. Additionally, Bill A would provide a “check box” on an appeal form to let clients note if they need special accommodations in an appeal hearing, such as an interpreter or ADA accommodations.
  • Bill B would strengthen the Administrative Law Judge’s role in safeguarding the rights of Medicaid clients. Currently, clients are able to question the sufficiency of their notice at an appeal hearing if they believe it is confusing or inadequate. If a judge finds that the notice is inadequate, the client can retain coverage until the state provides a more detailed explanation about why the benefits are being terminated. This procedural remedy gives clients an opportunity to understand why their health coverage is threatened and to prepare an appropriate response. Unfortunately, most Medicaid clients are not represented by an attorney and many are unaware they can require the state to provide more information about the basis for the decision and better prepare to challenge the proposed action. Bill B would rectify this problem, ensuring that an administrative law judge would automatically review the sufficiency of NOAs at the beginning of each appeal hearing. If a judge finds that a notice does not provide an adequate explanation, the client could elect to receive an improved notice, or they could choose to proceed with their hearing. The proposed legislation would help ensure that the right to adequate notice exists not only in theory, but in reality.
  • To prevent Medicaid notification issues from reoccurring, Bill C would direct the state to audit communications with Medicaid clients. These audits, which would take place in 2020 and 2023, would review notices for their legal sufficiency, clarity and accuracy. The audit findings, conclusions and recommendations will be presented to legislative committees, which can then consider whether the results warrant further reforms. The audits are a crucial component of confirming the successful implementation of any improvements that are made to Medicaid notices. Bill C would also help lawmakers assess how the reforms are working and enable them to draft legislative remedies to improve notification processes in the future.
  • Bill D aims to make notices more understandable, comprehensive and helpful. In particular, this bill would require plain-language statements explaining the loss or reduction of benefits while citing specific examples of the type of documentation that could help clients demonstrate their benefits should remain unchanged. For example, if a client needed to offer proof of income, the notice would list the types of documents (such as paycheck stubs) that the client could provide. Under the bill, notices would also include the client’s information relevant to their Medicaid eligibility, such as their recorded income. This information will help clients determine whether the loss of their benefits could be contested.

Collectively, these four proposals will help ensure that Medicaid clients do not lose access to health care due to the shortcomings in the current notification process.

While the interim committee only focused on Medicaid correspondence, these proposed improvements are needed in other essential public benefit programs. Whether health care, food, child care or financial assistance, a person’s access to public benefits should not be jeopardized by an ambiguous or confusing letter.

CCLP is proud to be supporting these four proposals during the 2017 legislative session.

– Jack Regenbogen

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HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

To maintain health and well-being, people of all ages need access to quality health care that improves outcomes and reduces costs for the community. Health First Colorado, the state's Medicaid program, is public health insurance for low-income Coloradans who qualify. The program is funded jointly by a federal-state partnership and is administered by the Colorado Department of Health Care Policy & Financing.

Benefits of the program include behavioral health, dental services, emergency care, family planning services, hospitalization, laboratory services, maternity care, newborn care, outpatient care, prescription drugs, preventive and wellness services, primary care and rehabilitative services.

In tandem with the Affordable Care Act, Colorado expanded Medicaid eligibility in 2013 - providing hundreds of thousands of adults with incomes less than 133% FPL with health insurance for the first time increasing the health and economic well-being of these Coloradans. Most of the money for newly eligible Medicaid clients has been covered by the federal government, which will gradually decrease its contribution to 90% by 2020.

Other populations eligible for Medicaid include children, who qualify with income up to 142% FPL, pregnant women with household income under 195% FPL, and adults with dependent children with household income under 68% FPL.

Some analyses indicate that Colorado's investment in Medicaid will pay off in the long run by reducing spending on programs for the uninsured.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

Hunger, though often invisible, affects everyone. It impacts people's physical, mental and emotional health and can be a culprit of obesity, depression, acute and chronic illnesses and other preventable medical conditions. Hunger also hinders education and productivity, not only stunting a child's overall well-being and academic achievement, but consuming an adult's ability to be a focused, industrious member of society. Even those who have never worried about having enough food experience the ripple effects of hunger, which seeps into our communities and erodes our state's economy.

Community resources like the Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, exist to ensure that families and individuals can purchase groceries, with the average benefit being about $1.40 per meal, per person.

Funding for SNAP comes from the USDA, but the administrative costs are split between local, state, and federal governments. Yet, the lack of investment in a strong, effective SNAP program impedes Colorado's progress in becoming the healthiest state in the nation and providing a better, brighter future for all. Indeed, Colorado ranks 44th in the nation for access to SNAP and lost out on more than $261 million in grocery sales due to a large access gap in SNAP enrollment.

See the Food Assistance (SNAP) Benefit Calculator to get an estimate of your eligibility for food benefits.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

Every child deserves the nutritional resources needed to get a healthy start on life both inside and outside the mother's womb. In particular, good nutrition and health care is critical for establishing a strong foundation that could affect a child's future physical and mental health, academic achievement and economic productivity. Likewise, the inability to access good nutrition and health care endangers the very integrity of that foundation.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides federal grants to states for supplemental foods, health care referrals, and nutrition information for low-income pregnant, breastfeeding and non-breastfeeding postpartum women and to infants and children up to age five who are found to be at nutritional risk.

Research has shown that WIC has played an important role in improving birth outcomes and containing health care costs, resulting in longer pregnancies, fewer infant deaths, a greater likelihood of receiving prenatal care, improved infant-feeding practices, and immunization rates

Financial Security:
Colorado Works

In building a foundation for self-sufficiency, some Colorado families need some extra tools to ensure they can weather challenging financial circumstances and obtain basic resources to help them and their communities reach their potential.

Colorado Works is Colorado's Temporary Assistance for Needy Families (TANF) program and provides public assistance to families in need. The Colorado Works program is designed to assist participants in becoming self-sufficient by strengthening the economic and social stability of families. The program provides monthly cash assistance and support services to eligible Colorado families.

The program is primarily funded by a federal block grant to the state. Counties also contribute about 20% of the cost.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

Child care is a must for working families. Along with ensuring that parents can work or obtain job skills training to improve their families' economic security, studies show that quality child care improves children's academic performance, career development and health outcomes.

Yet despite these proven benefits, low-income families often struggle with the cost of child care. Colorado ranks among the top 10 most expensive states in the country for center-based child care. For families with an infant, full-time enrollment at a child care center cost an average of $15,140 a year-or about three-quarters of the total income of a family of three living at the Federal Poverty Level (FPL).

The Colorado Child Care Assistance Program (CCCAP) provides child care assistance to parents who are working, searching for employment or participating in training, and parents who are enrolled in the Colorado Works Program and need child care services to support their efforts toward self-sufficiency. Most of the money for CCCAP comes from the federal Child Care and Development Fund. Each county can set their own income eligibility limit as long as it is at or above 165% of the federal poverty level and does not exceed 85% of area median income.

Unfortunately, while the need is growing, only an estimated one-quarter of all eligible children in the state are served by CCCAP. Low reimbursement rates have also resulted in fewer providers willing to accept CCCAP subsidies.