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Show Background on Utah's New Medicaid Waiver: Primary Care Network Rod L. Betit Over the last 10 years. Utah's health policy initiatives have contributed to Utah consistently having the lowest uninsured rates in the nation. The uninsured rates in Utah were reported at 8.7% for all ages and at 6.8% for children in 2001. Among those uninsured, approximately 85,000 were adults with family incomes below 200% of the federal poverty level (Utah Office of Public Health Assessment, 2002). Approximately three-fourths of these adults work, but most of their employers do not offer health insurance. Providing affordable health care to these uninsured working Utahns would improve their health status and potentially reduce the uncompensated health care burden on health care providers and insured Utahns. Unfortunately, limited state dollars are available to assist this population once Medicaid and the Children's Health Insurance Program (CHIP) are adequately funded. The policy question facing Utah is whether to wait for new federal funding to expand coverage to these low income working adults, or to push the federal government to offer a limited benefit plan for a subset of this population under Medicaid using untapped discretionary powers of the Secretary of the U.S. Department of Health & Human Services (DHHS). DEVELOPING THE PRIMARY CARE NETWORK (PCN) In March 2001, the Utah Department of Health (UDOH) Executive Director presented an innovative proposal for a new primary care benefit plan for low income working adults to Governor Michael O. Leavitt. Governor Leavitt in turn met with Secretary of DHHS Tommy Thompson. The Secretary immediately became an ardent supporter of the initiative, even though it would require him to grant exceptions to Medicaid policy not previously extended to individual states. On February 9, 2002 in Salt Lake City, Secretary Thompson and Governor Leavitt signed documents giving final approval to the new PCN with enrollment permitted up to 25,000 adults (16,000 parents and 9,000 singles/couples without children). Utah committed $3.5 million in state funding toward the program which when combined with Medicaid federal matching funds and recipient cost sharing, provided approximately $20 million in total funding for the program. The PCN Program began enrollment on July 1, 2002. As of April 1, 2003, it already has reached an enrollment of 14,000 adults. Enrollment continues to grow at an average rate of 400 adults per week. The following is a brief discussion of the program. WHO IS ELIGIBLE FOR PCN? Any U.S. citizen between 19-64 years of age who has not had health care coverage for at least six months, whose employer pays less than 50% of their health care benefit, and whose annual income is less that 150% of the federal poverty level is eligible for this program. WHAT BENEFITS WILL PCN OFFER? This is the first preventive benefit plan offered under Medicaid in the U.S. The PCN benefit plan includes primary care physician office visits, annual physicals, flu immunizations, urgent care visits, emergency room visits, lab, X-ray, ambulance transport, medical equipment, medical supplies, oxygen, basic dental care, hearing tests, vision screening but not eyeglasses, and prescription drugs. The benefit plan is comprehensive enough that Utah's major insurers have agreed to consider the enrollee's time spent in the program as credible coverage once they become eligible for traditional employer insurance. This will be a big benefit to those low income workers who become unemployed and cannot afford COBRA conversion policies. WHAT BENEFITS ARE NOT COVERED BY PCN? Services not include in-patient and out-patient hospital services; specialty physician care; non-emergency transportation to medical care by public transit or taxi; some dental care like or-thodontia, root canals, and crowns; mental health treatment; substance abuse treatment; physical therapy; occupational therapy; and chiropractic care. However, the UDOH has entered into an agreement with Utah's hospitals to provide up to $10 million annually in donated hospital care to the PCN population. Thus far over 300 PCN enrollees have been referred for hospital care under this arrangement. In addition, specialty physicians under separate agreements have provided donated specialty care to many PCN enrollees who needed them. Finally, the UDOH is working with the insurance industry to develop a low price catastrophic insurance policy that would cover hospitalizations above $5,000 per year that a PCN enrollee could purchase. WHAT ARE ENROLLEES REQUIRED TO PAY? Enrollees pay an annual enrollment fee of $50, plus co-payments similar to the CHIP'S co-payments. The annual out-of-pocket maximum payment is $1,000 per enrollee. WHY IS PCN IMPORTANT TO NATIONAL HEALTH POLICY? This is the first time the federal government has permitted a state to offer a limited benefit plan that does not include hospi-talization and specialty care under Medicaid. We believe that this DHHS decision recognizes that states cannot continue to extend full Medicaid coverage to the remaining uninsured. Full coverage is too costly, covers too few people, and encourages "crowd out," the phenomenon where people already insured in the workplace migrate to public coverage resulting in no reduction in the number of uninsured. Secretary Thompson agrees that states need new insurance products to help the remaining uninsured in this country, therefore PCN functions as a test. This test is particularly critical since a product similar to PCN is not available from the private insurance market. Utah's philosophy regarding PCN is to offer primary and preventive benefits to low-income working adults until their income allows them to afford more comprehensive coverage, or they become employed in a company that pays a larger share of their health care coverage. A recent amendment to PCN will allow a participant enrollee to use the value of their PCN coverage as part of their contribution to purchase their employers comprehensive health coverage. PCN's ultimate goals are to improve enrollees' health status and to reduce or contain the amount of uncompensated care donated by health care systems in Utah. Utah's primary Utah's Health: An Annual Review Volume LX 138 |