Rhode Island and the ACA’s Medicaid expansion

63% increase in RI Medicaid population; uninsured down to 4.6%

rhode-island Medicaid guide

Medicaid expansion in Rhode Island

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Rhode Island embraced the provision to expand Medicaid in 2014 under the Affordable Care Act (ACA). Federal funding covered the cost of expansion through 2016, after which the state began to pay 5 percent of the expense starting in 2017. That’s gradually increasing until 2020, when it will reach 10 percent. The 90/10 split in federal/state funding will remain at that level going forward. In other words, states that expand Medicaid will always get $9 in federal money for every $1 they spend to provide care for the Medicaid expansion population.

The state’s total Medicaid/CHIP population grew by more than 120,000 people (a 63 percent increase) from the fall of 2013 through August 2018. Only four states had larger percentage increases in their Medicaid/CHIP populations during that time. Not all of those people are newly-eligible as a result of Medicaid expansion, but many of them are. And Medicaid enrollment growth has been trending higher than the state projected.

According to U.S. Census data, the uninsured rate in Rhode Island dropped from 11.6 percent in 2013 to 4.3 percent in 2016, although it inched back up in 2017, to 4.6 percent (this was typical in many states; the national average uninsured rate was slightly higher in 2017 than it had been in 2016). Vermont was tied with Rhode Island for the fifth-lowest uninsured rate in the country in 2017; only three states and the District of Columbia had lower uninsured rates.

Kaiser Family Foundation estimated that only 55,000 people who were still uninsured in Rhode Island as of late 2015. And nearly half — 49 percent — were eligible for Medicaid.

Medicaid expansion

The ACA called for the expansion of Medicaid to cover all legally-present residents in the US with household incomes up to 133 percent of poverty level (138 percent with the built-in income disregard). But in the summer of 2012, the Supreme Court ruled that states could not be penalized for opting out of the expansion, and nearly half the states initially opted not to expand Medicaid.

But Rhode Island was among the states that moved forward with Medicaid expansion as called for in the ACA. Former Governor Lincoln Chafee made it clear immediately after the Supreme Court ruling that Rhode Island would be implementing Medicaid expansion and fully embracing the ACA (the state also set up its own state-run exchange).

Governor Chafee signed the fiscal year 2014 budget in July 2013, and it included a provision to expand Medicaid starting January 1, 2014. Eligible residents were able to begin enrolling on October 1, 2013, when the state’s health insurance exchange opened for business.

In 2013, Rhode Island estimated that there were about 40,610 low-income childless adults in the state who would be newly eligible for Medicaid starting in 2014. But by the end of 2016, CMS reported that 62,225 people were enrolled in expanded Medicaid in Rhode Island. And enrollment has continued to climb since then.

Am I eligible?

In addition to the aged, blind, and disabled, the following Rhode Island residents are eligible for coverage under Medicaid or CHIP:

  • adults with incomes up to 138 percent of poverty.
  • Pregnant women with household incomes up to 253 percent of poverty.
  • children with household incomes up to 261 percent of poverty.
  • Women with household incomes up to 250 percent of poverty who lose coverage under RIte Care (Medicaid managed care) 60 days postpartum are eligible for two years of Extended Family Planning coverage that provides gynecological check-ups and contraceptives.

Prior to 2014, non-disabled adults without children were ineligible for Medicaid regardless of their income.  The expansion of Medicaid has been particularly beneficial for this group.

How do I apply?

The state Medicaid office has worked together with HealthSourceRI (the ACA-created state-run exchange) to streamline the application process for Medicaid.  You can apply online via these websites:

Or you can print a paper application and mail the completed form to : HealthSourceRI, HZD Mailroom, 74 West Road, Suite 900, Cranston, RI, 02920-8413.

You can also call 855-609-3304 for phone assistance, or visit 70 Royal Little Drive in Providence for in-person assistance.  HealthSourceRI can help you find local in-person assistance as well.

RI Medicaid covers transgender healthcare

As of November 2015, Rhode Island joined eight other states and the District of Columbia in adding transgender healthcare to the covered services under the state’s Medicaid program. Rhode Island Medicaid now covers gender reassignment surgery and hormone therapy for transgender individuals.

Hepatitis C drug coverage expanded

Sovaldi and Harvoni have been heralded as miracle drugs for their ability to cure a significant percentage of Hepatitis C cases. But they’re breathtakingly expensive. As a result, many state Medicaid programs — including Rhode Island’s — required patients to meet a pre-determined set of criteria before the Hep C drugs could be prescribed. There were concerns, however, that states were too restrictive in setting their requirements, and the benefits of paying for Hep C treatment sooner and for more patients may outweigh the additional cost of the medication.

In 2015, Rhode Island was denying the majority of claims for Hepatitis C drugs. But in the spring of 2016, Medicaid director Anna Rader Wallack said that the issue was being revisited to determine whether Medicaid should take a larger role in covering the drugs that can cure Hepatitis C. And in early 2018, the state announced a new policy with regards to Hepatitis C treatment: Patients with Hepatitis C no longer need to have severe liver damage or cirrhosis in order to qualify for Hepatitis C drug coverage. That was welcome news for patient advocates, but the increased Medicaid spending for Hepatitis C has pushed Medicaid costs over budget.

Changing leadership

Rader Wallack served as director of HealthSourceRI (the state’s ACA exchange) for most of 2015. But in October 2015, she was appointed to lead the state’s Medicaid program instead. Rader Wallack began her new role at Medicaid in November 2015.

But less than a year later, in September 2016, she left RI Medicaid for a job at Brown University School of Public Health. Elizabeth Roberts, Rhode Island’s Secretary of Health and Human Services, appointed Deputy Medicaid Directors Deb Florio and Darren McDonald to run the state’s Medicaid program while the state conducted a search for a permanent director. In 2017, Patrick Tigue became the state’s Medicaid Director.

Eligibility determination system overhaul

Medicaid eligibility in Rhode Island has long been determined by the Office of Health and Human Service’s 25-year-old InRhodes system. In addition to verifying eligibility for Medicaid, InRhodes also determined eligibility for premium subsidies through HealthSourceRI, along with other public assistance programs.

The state began overhauling the InRhodes system in 2013, and had intended to finish the upgrade by 2015. But in October 2015, Rhode Island officials announced that the state received an additional $112.8 million in federal funds to continue upgrading the system, and the project was expected to extend into 2016.

The new system launched in September 2016, at healthyrhode.ro.gov. For the full upgrade, Rhode Island spent a total of $80 million and the federal government will spend a total of about $285 million. But state officials estimate that by 2018, the new computer system will have paid for itself via more efficient operations and effective ways to curb fraud and misuse.

Enrollment progress

As soon as Medicaid was expanded in Rhode Island, 64,590 people enrolled in Medicaid through HealthSourceRI between October 2013 and March 2014. Of that group, 34 percent were already eligible for Medicaid before the program was expanded, but may not have been aware of their eligibility. Although the federal government is paying nearly all of the cost of covering the newly-eligible population, the existing nearly 50/50 state/federal split in Rhode Island applies to any enrollees who were eligible based on the previous guidelines.

The increase in enrollment among previously-eligible people has caused some budget woes in RI, as it has in many other states. The enrollment of a significant number of already-eligible residents is known as the “woodworker” effect (people coming out of the woodwork) and was driven by the publicity and outreach surrounding the ACA’s exchanges and open enrollment.

Enrollment for Medicaid and CHIP are year-round, but tend to spike during the general open enrollment due to outreach from the exchanges. During the second open enrollment period, 65,396 HealthSourceRI enrollees were eligible for Medicaid or CHIP.

Prior to the first open enrollment, the prediction was that 51,000 newly-eligible Rhode Island residents would enroll in Medicaid by July 2015. But by March 2014, 42,320 newly-eligible residents had enrolled – about 83 percent of the total anticipated, more than a year ahead of schedule. And by the end of 2016, CMS reported that 62,225 people were enrolled in expanded Medicaid in Rhode Island. That number has continued to increase since 2016, and does not include the population that was already eligible for Medicaid but didn’t enroll until after the ACA-related outreach efforts.

Funding

In early 2015, Governor Gina Raimondo established the Working Group to Reinvent Medicaid, tasked with presenting innovative recommendations to modernize the state’s Medicaid program and increase efficiency. Their recommendations were unveiled in April, and included $85.5 million in state savings. Most of the group’s recommendations (amounting to $70.5 million) were included when Raimondo created the state’s health and human services budget for the 2016 fiscal year.

Medicaid spending is a significant portion of Rhode Island’s state budget. $1.9 billion of the state’s $8.5 billion budget was allocated for Medicaid in 2014, and the state announced in April 2014 that the cost of providing Medicaid coverage in the 2015 fiscal year would be $52 million more than originally anticipated.

When the budget was released for the 2016 fiscal year that began in mid-2015, it included $2.3 billion for Medicaid. Officials announced in October 2015 that they expected a relatively small Medicaid budget deficit for the 2016 fiscal year: $5.7 million, which is only a quarter of one percent of the state’s current $2.3 billion Medicaid budget. And although the FY 2016 budget included more than $70 million in cuts to the Medicaid program, officials noted that the state wasn’t quite on target to meet all of the spending cut goals, and would possibly miss the savings mark by up to almost $11 million in the 2016 fiscal year.

As of 2018, Medicaid spending in Rhode Island was more than $18 million over budget, but the vast majority of that was being picked up by the federal government, since Medicaid expansion costs are mostly covered by federal funds.

Medicaid history in Rhode Island

The first states to implement Medicaid did so in January 1966, and Rhode Island wasn’t far behind them – Medicaid became available in the state in July 1966. Rhode Island uses a Medicaid managed care model to provide coverage.  RIte Care and Rhody Health Partners (UnitedHealthcare) are the managed care providers in the state. RIte Care is for pregnant women and children, and utilizes UnitedHealthcare Community Plan of New England or Neighborhood Health Plan of RI to provide coverage.

RIte Share is a premium assistance program that pays all or a portion of an eligible employee’s share of employer-sponsored health insurance premiums.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

How to apply in RI

Online at HealthSourceRI or HealthyRhode.ri.gov, or you can use a paper applicationHealthSourceRI can also help you find local in-person assistance.

Eligibility: The aged, blind, and disabled.  Also, adults with income up to 138% of poverty, pregnant women with income up to 253% of poverty, and children with incomes up to 261% of poverty.

Rhode Island section