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Enrollment Data for Indiana’s Medicaid Waiver Raise Questions

Before and after the federal government approved the Healthy Indiana Plan (HIP) 2.0, the state’s plan to expand Medicaid, we raised concerns that charging premiums and co-pays to low-income Medicaid beneficiaries would limit their participation and access to care.  Now, enrollment reports released since Indiana launched HIP 2.0 in February raise questions that need answers before the federal government lets other states take similar approaches to Medicaid expansion.

In HIP 2.0, people with incomes below the poverty line pay a premium of 2 percent of income or $1 per month, whichever is greater, to enroll in the “Plus” plan.  If they don’t make the monthly payments, they’re enrolled in the “Basic” plan, which covers fewer benefits and has co-pays for prescription drugs, doctor’s visits, and other services.  HIP 2.0 is testing whether monthly contributions in lieu of cost sharing in HIP Plus “will affect enrollment, utilization, and the use of preventive and other services by beneficiaries.”  How many uninsured people enroll and whether they make monthly premium payments are key questions in judging HIP’s success.

Indiana estimated that HIP 2.0 would cover about 350,000 uninsured Hoosiers.  The state recently suggested that Indiana is close to that target, with 297,000 people enrolled, but a close look shows that’s not the case. That’s because when Indiana launched HIP 2.0 in February, it transferred 180,000 enrollees from other programs — 60,000 from HIP 1.0 and 120,000 from Indiana’s Medicaid program for parents and pregnant women.

Recent media reports about Indiana’s progress don’t mention the transferred groups or mention only the 60,000 from HIP 1.0.  While some beneficiaries who were transferred into HIP 2.0 likely have left the program and been replaced by new beneficiaries, many remain and shouldn’t count in the totals in order to give a true picture of how close Indiana is to meeting its enrollment target. 

In addition, monthly reports that the state provides to the federal government that break down enrollment by income are at odds with what would be expected, based on Census data on the uninsured.

Nationwide, only 8 percent of uninsured adults aged 19 to 64 have incomes below 5 percent of the poverty line, and 14 percent have incomes below 50 percent of the poverty line, new Census Bureau data show.  Indiana’s September enrollment report shows that about one-third of enrollees are in Basic and two-thirds in Plus.  Also, 53.4 percent of enrollees have incomes below 5 percent of the poverty line.  Overall, about two-thirds have incomes below 50 percent of the poverty line.

That such a large share of HIP 2.0 enrollees have very low incomes — particularly the very large share with little or no income — raises serious questions about how Indiana is assessing enrollees’ income, which determines how much they must pay to participate in HIP Plus.  These questions about HIP 2.0 enrollment should be answered before the federal government allows other states to adopt similar plans.