Florida Health Justice Project comments on TennCare III’s waiver of retroactiveMedicaid eligibility (RME).

Florida Health Justice Project (FHJP) submits comments on TennCare III’s waiver of retroactive  Medicaid eligibility (RME). We urge that Tennessee’s waiver request to continue with the elimination  of RME be rejected and that RME be restored. 

FHJP is a nonprofit health advocacy organization whose mission is expanding access to healthcare  with a focus on Florida’s most vulnerable populations. 

Waiver of Retroactive Medicaid Coverage in TennCare III 

Tennessee TennCare III’s waiver of retroactive Medicaid coverage essentially requests permission to  continue the denial of RME, a critical consumer protection for vulnerable populations.  Unfortunately, Florida has also received an 1115 waiver to eliminate RME for non-pregnant adults— and we have seen the harm caused by this waiver.  

We are deeply concerned about the harmful impact of this waiver on beneficiaries and ask the  Secretary of the U.S. Department of Health & Human Services (HHS) to withdraw its authorization  for Tennessee to continue this experiment. HHS is authorized to take this action when it finds that the  experiment is not likely to achieve the statutory purposes of Medicaid. 1 That purpose is to promote  coverage, not take it away. 

"George's" story is a perfect example of how elimination of RME hurts low-income Floridians and  safety net providers. In late January 2020, George suffered a heart attack and was rushed to the  hospital. The paperwork for his Medicaid coverage was filed in February. Because his application was  not submitted during the month of his hospitalization, he received a bill for $62,000. This created  significant stress for George and his family that would have been preventable before the elimination of  retroactive coverage given his minimal income (only $1100/month), he will never be able to pay the  hospital bill, and a critical safety net provider will be further stressed. 

FHJP’s comments submitted to HHS at the time that Florida initially sought this waiver in 2018 are  equally relevant today. Moreover, this experiment should also be considered in the context of research 2 showing crushing medical debt across the country, but highest in states like Tennessee and Florida that  have not expanded their Medicaid programs. Taking away retroactive coverage exposes thousands of  Tennesseans, primarily seniors and people with disabilities, to even more medical debt. It also  disproportionately impacts people of color as Black families are nearly twice as likely as White families  to obtain their health coverage through Medicaid. 3 The denial of retroactive Medicaid coverage  compounds the already present racial disparities and inequities in health.  

Continuing this waiver during the still ongoing pandemic and economic downturn is particularly  cruel given massive job and insurance coverage losses. Uninsured people face even greater risks of  facing substantial medical debt due to high treatment costs for COVID-19. The resulting health and  economic suffering could be greatly mitigated through reinstatement of retroactive Medicaid  coverage. 4
 
Section 1115 waivers are supposed to help states experiment with novel program components, but this  is not novel or experimental. Retroactive Medicaid coverage has already been cut in other states, such  as Florida, and imposes ruinous medical debt on the most vulnerable population.  

The State claims that this experiment will allow money to be saved and reinvested in the TennCare  program, but it really leaves money on the table by the State refusing to expand Medicaid.  

Those in the coverage gap -- people without a severe disability or with income above the Medicaid  limits, who do not make enough money for a subsidized Marketplace plan -- are facing a double  injustice merely by accident of geography. Because they live in Tennessee, a state that (like Florida) has  not expanded Medicaid, they have no ability to enroll in ongoing coverage when they are healthy and,  when they become sick enough to qualify for Medicaid, Tennessee denies them the lifeline of  retroactive coverage for medical bills incurred due to the illness or accident that led to their qualifying  disability. Simply put, Tennessee's elimination of retroactive Medicaid coverage results in devastating  medical debt for individuals who are unexpectedly rendered disabled. That result does not, as this  experiment requires, promote Medicaid coverage. 

10-Year Waiver Extension 
Finally, we join with Tennessee Justice Center in respectfully requesting HHS to withdraw the 10-year  extension of Tennessee's 1115 waiver. This extension was granted late in January 2021 during the  transition to the new federal administration. 
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Thank you for your consideration of these written comments and please let us know if you have  questions or need additional information. 

Sincerely, 
​Florida Health Justice Project

​1) 142 U.S.C. § 1315
2) S. Kliff, M. Sanger-Katz, "Americans Medical Debts Are Bigger Than Was Known Totaling $140 Billion," New York  Times, July 20,2021, https://www.nytimes.com/2021/07/20/upshot/medical-debt-americans-medicaid.html
3) https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/
4) P. Shafer, et al., "Medicaid Retroactive Eligibility Waiver Will Leave Thousands Responsible for Coronavirus Treatment  Costs, " May 8, 2020, Health Affairs,  https://www.healthaffairs.org/do/10.1377/hblog20200506.111318/full/

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