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Utah health officials are proposing lifetime limits and work requirements for childless adults who would gain coverage under a Medicaid expansion plan, hoping the changes will help persuade the federal government to approve it.
The proposals, announced Monday, also would affect some Utahns already covered by Medicaid such as a new $25 copayment charged to beneficiaries who go to an emergency room when a sickness or injury is not an emergency.
The state seeks to expand its Medicaid program to cover about 6,000 childless adults who are in three groups: those who are chronically homeless, going through the justice system or in need of mental health or substance-abuse treatment. Health officials initially submitted their plan last summer, with the goal of beginning enrollment on Jan. 1, 2017.
But the federal Centers for Medicare and Medicaid Services (CMS) still has not approved it more than six months later, leading the Utah Department of Health to propose tacking on limits that previously were nonstarters under President Barack Obama.
A 30-day public-comment period now begins, and the first of two public meetings will be held Thursday.
Rep. Jim Dunnigan, R-Taylorsville, who last year sponsored the bill that shaped the small-scale Medicaid expansion, said the changes came in response to the Trump administration's request that state officials be straightforward about what they wanted.
"This is quite frankly refreshing, because it's the first time I can remember that the administration has said, 'Just tell us what you want,' " he said.
The childless adults who would be added to Medicaid would face these limits:
• Enrollment would be capped at 25,000. The state would be allowed to set its own caps on each of the three groups the chronically homeless, criminal defendants or those needing mental health or substance-abuse treatment. Nate Checketts, director of the state Department of Health's Division of Medicaid and Health Financing, said caps will help the state stay on budget each year.
• The number of months they could receive coverage would be capped at 60 months over a lifetime. The same cap would apply to adults covered by the Primary Care Network, which covers less care than Medicaid.
• They would not receive 90-day retroactive coverage after enrolling, a benefit Medicaid extends to current beneficiaries. Instead, their coverage would begin the first day of the month they apply, if they are deemed eligible during that month.
"We want people to get signed up ahead of time," Dunnigan said. "We don't want them to wait until the house is on fire [to get] a fire insurance policy."
The state's amendments also would change coverage rules for Utahns who currently qualify for the Primary Care Network or Medicaid coverage.
• Medicaid beneficiaries would be charging a $25 copayment for going to the emergency room when the sickness or injury is not an emergency. Dunnigan said it is intended to direct people to an urgent care faculty, "which is one-tenth the cost."
• Those currently covered by the Primary Care Network would be required to participate in job training and-or job searching unless they meet one of 11 exemptions, including being 60 or older, being physically or mentally unfit to work and being responsible for a dependent child under age 6.
Checketts said the amendment would allow the state to apply this requirement to the newly eligible childless adults at a later date.
Dunnigan said studies in other states have shown that "there's a fair percentage of folks who are able-bodied adults who could work."
But Micah Vorwaller, health policy analyst for the Utah Health Policy Project, said research shows that work requirements don't actually make a difference.
"The vast majority of people on Medicaid are already working," Vorwaller said.
Dunnigan said he doesn't believe the changes require legislation, and if they did, "I don't know why there wouldn't be support."
But Vorwaller said he doesn't understand why the health department is proposing the changes when "there has been no political mandate to do so."
He also isn't sure whether these changes will affect the speed or likelihood with which Trump's administration approves the waiver.
"Conceivably, I could see how the Trump administration could want to approve these types of waivers ... with these more strict or conservative principles," he said. "But at the same time, it seems like CMS is waiting and not acting on much in the Medicaid area" because of the pending federal health care bill.
Before sending the adjusted plan to the feds, Checketts said, the department will seek spoken and written public comment.
They anticipate enrolling individuals by Jan. 1, 2018, which Checketts and Dunnigan believe is "realistic."
Health Department officials have scheduled two public meetings:
• 2 p.m. to 4 p.m. Thursday in Room 125 of the Cannon Health Building, 288 N. 1460 West, Salt Lake City.
• 3 p.m. to 5 p.m. July 10 at the same location.
Interested Utahns also can submit comments online at health.utah.gov or via mail to Jennifer Meyer-Smart, Utah Department of Medicaid and Health Financing, P.O. Box 143101 Salt Lake City, Utah 84114-3101.
Utah's initial expansion plan also extended coverage to more low-income parents with dependent children.
But the state has since submitted and the federal government has approved a separate plan for them, and the state expects to begin enrolling an estimated 3,000 to 5,000 parents July 1, Checketts said.
Tribune reporters Matthew Piper and Kelly Gifford contributed to this story.