By Danielle Parnass, CQ Staff
August 8, 2008 -- A new report from Georgetown University says poor implementation of West Virginia's redesigned Medicaid plan is hurting many children who have been blocked from the plan's enhanced benefits program because of confusing enrollment instructions, among other issues. Meanwhile, state officials rejected the findings of the report and said it is too soon to tell how the new program will fare.
The report from Georgetown's Center for Children and Families (CCF) found that around 93 percent of children were getting reduced coverage of health care benefits based on the West Virginia Medicaid Redesign, created to promote healthy living and combat preventable illnesses through smoking cessation, regular doctor visits and weight loss.
Eligible families who sign an agreement to engage in healthy behaviors receive enhanced benefits but those who do not are automatically enrolled in a basic plan that offers less coverage than Medicaid's traditional program. Doctors are required to assess patients in the enhanced benefits program each year to make sure they comply with the standards for healthy behavior. If they do not, they are placed back into the basic plan.
So far, a low number of children—about 8 percent of those eligible—are signed up to receive the enhanced benefits package, according to the report, which attributes the sluggish enrollment largely to implementation issues. Medicaid beneficiaries are given 90 days of their eligibility redetermination date to enroll in the enhanced program before being dropped to the basic program.
The report said informational materials about how to enroll in the enhanced program are hard to understand and do not clearly state where or how to send the completed agreement.
"What we found is extremely troubling," said Joan Alker, deputy executive director of the CCF. "It's been so poorly implemented that all of these families are just being defaulted."
Shannon Landrum, a spokeswoman for the West Virginia Bureau for Medical Services, said the program is still new and it is too soon to assess its effectiveness. As people become more familiar with the program, member agreements keep increasing: more than 14,000 member agreements have now been submitted since it was implemented in 2006 of the roughly 140,000 who are eligible, according to the most recent data, she said.
She also said some people may not have enrolled in the enhanced plan because the basic plan "is extremely good health care coverage."
Critics of the basic package say it only covers four prescriptions per month for each person enrolled and restricts mental health care, making the package much more limiting than the traditional plan, they said.
Landrum said the basic program is "only an appropriate benefit package for healthy kids," and only targets healthy children and adults who were enrolled in Medicaid because of low-income and not because of disabilities. "We have no intention of applying this benefit package to other populations," she said.
Landrum said the agency offers the ability to override the prescription limit if needed, and noted that drugs for conditions such as asthma and diabetes, as well as birth control medications, are not limited. She also said the basic package covers unlimited visits to psychologist and psychiatrists for adults and children, but certain limits on mental health service offerings only apply to adults.
Alker said there is a higher incidence of chronic conditions among children on Medicaid simply because they're poor. A 2000 study by CCF found that four of 10 kids with conditions like diabetes and asthma come onto Medicaid because of their income and not through the disability category, and Alker said this has likely grown because Medicaid enrollment has increased.
The redesigned program was originally implemented because West
Virginia is one of the unhealthiest states in the nation and has some of the highest rates of type 2 diabetes, heart diseases, and high blood pressure, Lundrum said. The new plan received much support from the Bush administration and was approved by the Department of Health and Human Services within eight days, raising many questions at the time about whether children would receive certain benefits, Alker said.
"It really takes a partnership," Lundrum said. "You can't pay for wellness if you don't have the patient participating in their health decisions.
Alker said it is only possible to improve people's health if they also are actively engaged in the process. The West Virginia program so far has not achieved that goal, she said.
Landrum said the internal response to the report has been "livid" and said the authors did not contact the department to discuss the issues.
"We think that the report . . . is an oversimplification of what's happening with the Medicaid program and we truly wish they would have called to ask us about it."
