Gov. Josh Stein and the North Carolina Department of Health and Human Services submitted apublic commentto the federal Centers for Medicare & Medicaid Services last week urging CMS to reverse course on its recent interim rule and revert to original language on medical frailty in H.R. 1 to protect health care coverage for more than 64,000 North Carolinians with cancer and other severe illnesses
“We have laws protecting vulnerable people because Congress recognized that people with life-threatening illnesses cannot afford to lose their access to health care,” Stein said. “The new federal guidance would upend that essential care and make it harder for some of the sickest Medicaid beneficiaries to keep their coverage. This guidance also would pose new burdens on health care providers and county staff. I am calling on CMS to reverse course and protect people’s health care.”
In H.R. 1, Congress established protections for people with serious or complex medical conditions, substance-use disorder, disabling mental disorders, or disabilities so that they would not lose health care coverage if they could not meet new Medicaid expansion work requirements. Despite Congress’s intent to preserve health care for these populations, CMS issued a new rule that is in conflict with that protection and puts vulnerable North Carolinians at risk of losing their health care, potentially while they are in the middle of receiving treatment.
These expected losses in coverage from the change in how medical frailty is determined come on top of the more than 255,000 people enrolled through Medicaid expansion who are likely to lose critical health care because of H.R. 1, including new work requirements and twice-a-year recertification requirements for Medicaid expansion. These changes will increase the number of people who are uninsured in North Carolina, compounding the number of North Carolinians who have lost their health coverage since Congress allowed ACA tax credits to expire last year. A greater uninsured population creates more strain for hospitals and the overall health care system, including by increasing emergency room visits when patients no longer have access to their doctors. Increased utilization of emergency rooms ends up raising health care costs for everyone through higher insurance premiums and hospital bills.
Medical frailty is an exemption category designed by Congress to allow people with complex medical conditions to maintain necessary coverage without additional documentation requirements. The CMS Interim Final Rule on Medical Frailty adds additional burden on the Medicaid beneficiary to prove that their illness significantly impairs their ability to work. Because of this change, the beneficiary may need to get documentation of this impairment from their provider
Before now, states had been relying on CMS guidance and have been planning for nearly a year to implement H.R. 1 requirements using claims data and diagnosis-based codes as the primary mechanism to verify that a person meets the definition of “medically frail.” The new interim final rule will add more manual work for county staff who are already stretched thin and limits NC Medicaid’s ability to efficiently streamline applications and redeterminations based on existing data
“We all agree that the best way to build healthy and safe communities is to increase access to health care,” said Melanie Bush, NCDHHS deputy secretary for Medicaid. “However, the new federal guidance on medical frailty will lead to a greater number of eligible individuals losing coverage because of the new narrower medical frailty definition, administrative complexity, and operational barriers.”
In addition to increased burden on patients and providers, CMS’s new definition of “medical frailty” will shift more work onto county staff. North Carolina is one of nine states that are state-supervised and county-administered in determining Medicaid eligibility. The new rule puts pressure on county staff, who are already stretched thin, to navigate a change in exemption rules for people who are medically frail while also implementing work requirements and twice-a-year recertification for the nearly 740,000 people who are on Medicaid expansion in North Carolina.
Stein has remained committed to protecting North Carolinians’ health care in the wake of changing federal guidance. Before H.R. 1 went into effect, Stein sentmultiplelettersto North Carolina’s Congressional delegation sharing the negative impacts of the bill on North Carolinians’ health care. Since the passage of H.R. 1, Stein has worked with federal, state, county, and local stakeholders to mitigate its impacts and ensure Medicaid was fully funded to protect health care coverage for millions of North Carolinians.
Stein has also co-chaired the National Governors Association’s Public Health and Emergency Management Task Force alongside Missouri Governor Mike Kehoe and leveraged this position to press CMS for H.R. 1 guidance that would protect North Carolinians
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