Governor Matt Bevin’s proposal for a Medicaid waiver to change Kentucky’s successful coverage expansion would remove vision and dental care from the state’s current Medicaid benefit package. Instead, if beneficiaries completed “specified health-related or community engagement activities” they’d get rewards to help pay for vision and dental care. Evaluations of similar incentive programs in Iowa and Michigan show that few people in Kentucky would likely earn rewards, leaving beneficiaries without access to care that’s now covered.
Iowa’s waiver program, through which it expanded Medicaid in 2014, requires beneficiaries with incomes at or above 50 percent of the poverty line to pay premiums after they’re enrolled in the program for a year, but premiums are waived if they get a wellness exam and complete a health risk assessment (HRA). Medicaid pays providers an extra $25 to help enrollees complete the assessment. Despite these incentives, just 17 percent of enrollees with incomes below the poverty line and 8 percent with income above it qualified for a premium waiver in 2015. Moreover, a survey of clinic managers showed they had “very limited awareness and knowledge of the program.” The evaluators concluded that “the number of members who have completed either the wellness exam or the HRA is suboptimal.”
In Michigan’s expansion waiver, beneficiaries receive incentive payments that offset their liability for cost-sharing if they complete a health risk assessment. The state’s enrollment broker helps beneficiaries complete the first part of the assessment, and the vast majority of enrollees finish that. But to earn an incentive, beneficiaries must complete the rest of the assessment with their health care provider during a preventive health visit. Only 14.9 percent of beneficiaries enrolled in a health plan for at least six months qualified as of December 2015. “Most beneficiaries did not know about the connection between completion of the health risk assessment and the healthy behavior reward,” interviews with them revealed.
Medicaid waivers are meant to promote Medicaid’s objective of delivering health care services to vulnerable populations who can’t otherwise afford them. Kentucky’s waiver proposal states that the rewards program “will encourage healthy behaviors and increase member access to enhanced health services.” Iowa and Michigan’s experience show that Kentucky will likely fall far short of the goal: few beneficiaries will get the vision and dental care they now receive.