Wins and Losses for Health Care in New York’s Budget

Empire Justice April 27, 2017

Funding for Health Care Consumer Advocacy Programs
The final 2017 New York State budget continues funding for two important programs that assist individuals and small employers in New York so that they are able to effectively use health insurance coverage and access quality health care:  the Managed Care Consumer Assistance Program (MCCAP) and Community Health Advocates (CHA).

MCCAP is a statewide New York State Office for the Aging (NYSOFA) initiative that funds five nonprofits to provide critical assistance to seniors and people with disabilities so they can access Medicare services and reduce health care costs.  The enacted budget continues funding for MCCAP at its current level, $1.767 million.

The enacted budget provides $3.5 million for Community Health Advocates (CHA), a statewide program that helps insured individuals navigate their health plan, and helps both insured and uninsured New Yorkers access necessary health care and resolve billing disputes. The CHA funding in the budget includes a much appreciated $1 million allocation from the Assembly Majority, which is a $250,000 increase over last year’s Assembly allocation for CHA.  Although this increase still leaves the program $500,000 short of its funding level before a cut last year, it will help CHA reach more people and allow the program to be there to help New Yorkers cope with the uncertainty and fear that federal threats to Medicaid and the Affordable Care Act have created.

Keeping Down Health Care Costs for Low Income New Yorkers: A Mixed Bag
With respect to keeping down health care costs for low income New Yorkers, the final budget had some wins and a loss.

First the good news:

  • The Governor’s proposals to increase costs for Essential Plan members were rejected.  Therefore premiums and cost sharing for Essential Plan members will remain at their current levels for state fiscal year 2018 (April 1, 2017-March 31, 2018).
  • A proposal to increase the copay for Medicaid over-the-counter medication to $1 was also rejected.
  • The copay for non-preferred drugs in the Medicaid program is lowered from $3 per prescription to $2.50.  Non-preferred drugs are those that are not on the fee-for-service Preferred Drug List, and those drugs that are not on a Medicaid managed care plan’s formulary.  This change is effective July 1, 2017.

Unfortunately, starting July 1, 2017, Medicaid recipients are facing a substantial increase in the copay for brand name formulary drugs and brand name drugs on the Preferred Drug List.  The copay for these medications will increase from $1 to $2.50.  It is important that Medicaid recipients are reminded that if they cannot afford the copay at the time they seek to pick up a medication, the pharmacy still must provide the medication.  While the pharmacy has the option of billing a Medicaid recipient for the copay later, medication may not be denied at the counter.

Proposed Medicaid Reductions Rejected
In what has become an annual occurrence, the enacted budget rejected two executive proposals that would have decreased access to Medicaid services, and which Empire Justice Center strongly opposed:

  • The enacted budget, once again, rejected the Governor’s proposal to eliminate spousal and parental refusal protections, which are critical to helping some adults and children access Medicaid and Medicare services they otherwise could not obtain or afford.
  • The enacted budget rejected the Governor’s attempt to eliminate from the Medicaid fee-for-service and managed care programs the important prescriber prevails protections for prescription medications.  Prescriber prevails protections permit doctors with intimate knowledge of their patients’ diagnoses and histories to have final say over what medications are necessary and appropriate for their patients.

New Medicaid Covered Services for Women and Infants
The final budget adds two benefits to the Medicaid program: coverage of donor breast milk and support for infertility treatment.

Beginning in July, Medicaid will cover donor breast milk in the hospital for infants who have a very low birthweight (less than three pounds, four ounces), have a condition that puts them at risk of a serious intestinal condition called necrotizing enterocolitis, or who have a condition that could benefit from receiving donor breast milk.  The Department of Health is expected to provide a description of, or guidance on, what conditions would fit the last category.  To be eligible for donor breast milk, the infant either needs to be unable to breast feed or the mother must be unable to breast feed or produce sufficient quantities of milk.  This new benefit will help save the lives of babies born prematurely and expose them early on to the beneficial effects of breast bilk.

Medicaid is also expanding to provide a limited benefit around infertility treatment.  The scope of the benefit is open to interpretation.  It minimally will cover blood testing, ultrasounds and other services to monitor women who are receiving ovulation enhancing medication.  However, it is not clear whether Medicaid will cover the fertility drugs themselves or whether women will have to obtain coverage for those medications through other insurance or by paying out of pocket.  Medicaid’s coverage of this new benefit is linked to the State’s ability to receive a 90% federal match for the services.  If that match is not available, a state-funded grant program will be set up to fund the benefit.

Home Care Aide Shortage
During two Assembly hearings in February, 86 people, including home care recipients and home care workers, and representatives from provider agencies, health plans and advocacy organizations, testified about a critical shortage of home care aides across the state, but particularly outside of New York City and Long Island.  Empire Justice was disappointed that the final budget failed to adequately address this widespread home care workforce shortage, driven by inadequate wages, that has left people with disabilities and seniors stuck in nursing homes, unnecessarily hospitalized, or putting their health and safety at risk at home without sufficient aide services.

 Liz Seigel and Amy Lowenstein testify on the home health aide crisis in February, 2017.

Both houses of the legislature had additional budget proposals that represented steps towards addressing the home care workforce shortage, including proposals to require the state to adequately compensate Medicaid managed care plans so that they in turn are able to fund a workforce sufficient to provide services to people who need a high level of homecare.  To ensure that increased payments to Medicaid plans and home care providers would be used to increase access to services, the Assembly proposal also included language that resources must be made available to support workforce recruitment, training and retention.  In the end, none of these proposals made it into the enacted budget.  However, the health budget side letter does commit the Department of Health to engage stakeholders, including advocates, in exploring ways of adjusting payments to managed care plans to address the costs of high needs individuals in the community.  The hope is that a community high needs rate cell will allow people with extensive home care needs to receive appropriate care in the community and help plans have sufficient funds to ultimately attract and retain more home care workers.  Empire Justice Center, through its role on the steering committee of Medicaid Matters New York, has already reached out to the Department to express its interest in being a part of these important discussions.