Earlier this summer, Wolfe enrolled in the program and received a letter from the state. The letter informed him that he would need to make monthly payments starting in July to maintain his coverage. These payments, often called POWER account contributions, are based on his income.
Wolfe expressed uncertainty about the duration of his coverage, and he is not alone in having queries about his insurance.
The state was not in agreement with the ruling.
“According to Cora Steinmetz, Indiana’s Medicaid Director, these actions are believed to have unintended consequences for our program. The ruling has brought about uncertainty regarding the coverage of certain services and has also removed the authority for certain administrative aspects of the program’s operation.”
A safety net that doesn’t catch all
Advocates and policy experts argue that certain policies within Indiana’s Medicaid expansion program pose obstacles to accessing life-saving health insurance coverage. These policies have resulted in confusion and the unnecessary removal of thousands of individuals from Medicaid, even though they still meet the eligibility criteria and require the coverage.
According to Leo Cuello, a public policy expert from Georgetown University’s Center for Children and Families, the implementation of such policies often leads to a decrease in enrollment. This is evident in numerous studies conducted across different states, which highlight the negative impact of high premiums on individuals seeking coverage.
The lawsuit brings attention to additional concerns regarding Indiana’s Medicaid expansion, going beyond just the cost of premiums. These concerns include the absence of retroactive coverage and the absence of guaranteed non-emergency medical transportation.
For decades, Medicaid has included retroactive coverage, which helps individuals by covering medical bills from up to three months ago. This provision was designed to assist people who find themselves in financial distress due to unexpected illnesses or injuries.
According to the federal judge who overturned the approval of Indiana’s program, approximately 60,000 individuals in Indiana lost their coverage from 2015 to 2016 due to their failure to make these payments. This accounts for around one-third of the enrollees who were required to pay premiums at that time.
Since then, approximately 40 states, along with the District of Columbia, have taken the initiative to expand Medicaid coverage for individuals with lower incomes.
In 2015, Indiana made the decision to expand its Medicaid under the ACA. However, the state imposed certain conditions, one of which was the ability to charge premiums. Indiana justified this by stating that the premium payments encouraged personal responsibility in healthcare coverage. As a result, in 2020, Indiana’s waiver was granted approval for an additional ten years.
However, it is worth noting that there have been objections and concerns raised regarding the federal government’s approval of waivers and how the state implements the HIP program.
In a letter to Indiana in 2023, HHS acknowledged the significant evidence indicating that premiums can limit access to coverage and care. However, HHS decided not to take any action against the state, as they believed that implementing changes to coverage at that time would cause unnecessary disruption.
Indiana’s approval for charging premiums over the course of a decade stands in contrast to the trend observed in many other states, which have either voluntarily or forcibly abandoned the practice. In fact, the Department of Health and Human Services (HHS) has relied on data gathered from Indiana to support their decision to phase out premiums in other states, as it became evident that these premiums were resulting in a loss of coverage.
According to Cuello, Medicaid premiums have been gradually phased out over time. Currently, there are only a few programs that still require premiums, and even those are being phased out. As a result, premiums are becoming a thing of the past.
The Future of the Healthy Indiana Plan
Indiana’s Family and Social Services Administration, the organization responsible for overseeing Medicaid, has taken action to delay the implementation of the federal ruling. State officials have expressed concerns that if the ruling is enforced, they will be required to shift approximately 335,000 members from the more comprehensive HIP Plus plan to the less extensive HIP Basic plan.
The state argues that the ruling poses a threat to Indiana’s long-term sustainability of HIP.
State officials expressed their concerns about the repercussions of the District Court’s ruling in July. They highlighted the far-reaching nature of the ruling and the resulting uncertainty it has created for the HIP program. The officials also pointed out that certain implications of the ruling are in conflict with state law, potentially jeopardizing the state’s ability to offer health care coverage to the Medicaid expansion group.
Advocates, as well as the judge presiding over the case, contend that there is no necessity for the state to maintain premiums. Indiana demonstrated its ability to offer extended coverage to its members during the four-year period of the COVID-19 public health emergency, during which the federal government prohibited the disenrollment of individuals from Medicaid. Throughout this time, Indiana enrolled all members in the HIP Plus program, without imposing any premium charges.
The plaintiffs have responded to Indiana’s motion to stay the ruling, arguing that Indiana is trying to portray a scenario of significant disruption, but much of the disruption would be caused by the state itself. They pointed out that for over four years, the beneficiaries of the expansion group have been enjoying HIP Plus coverage without paying any premiums, which is the current state of affairs.
Advocates like Hutchings-Goetz believe that the state is unlikely to completely terminate the HIP program. They argue that such a move would have far-reaching consequences for hospitals, providers, and employers who depend on Medicaid.
According to her, the elimination of HIP would have dire consequences for the residents, healthcare systems, and economy of the state.
However, the situation may undergo a transformation in the coming days as the state’s appeal navigates its way through the judicial system.
He expressed that his only knowledge of the trial is what makes him believe that he doesn’t have to pay.
You can contact Abigail Ruhman, the health reporter for Indiana Public Broadcasting, at aruhman@wboi.org.
You can contact Ben Thorp, WFYI’s enterprise health reporter, at bthorp@wfyi.org.
This story is a result of a collaboration between Indiana Public Broadcasting, WFYI, and Side Effects Public Media.
Side Effects Public Media, a health reporting collaboration based at WFYI in Indianapolis, partners with NPR stations across the Midwest and surrounding areas. This includes KBIA and KCUR in Missouri, Iowa Public Radio, Ideastream in Ohio, and WFPL in Kentucky.