CIDRAP-Recent Medicaid ruling is a reprieve for HIV/AIDS community

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Recent Medicaid ruling is a reprieve for HIV/AIDS community

www.cidrap.umn.edu

Recent Medicaid ruling is a reprieve for HIV/AIDS community​

Sarah Boden

Today at 1:26 p.m.
HIV/AIDS


Americans with HIV and other complex medical needs got mostly good news about their Medicaid coverage last week.

A ruling out of the US District Court in Boston found that the Centers for Medicare and Medicaid Services (CMS), led by Mehmet Oz, MD, exceeded its regulatory authority with a provision that sought to limit which Medicaid enrollees are exempt from a new work requirement by narrowing the definition of "medically frail."

Judge Richard G. Stearns, however, upheld two other CMS provisions affecting medically frail adults that were opposed by states that sued CMS. The plaintiffs had argued, in part, that these new administrative hurdles from CMS would inflict harm and chaos.

Because Medicaid is a publicly funded insurance program for low-income people, advocates and policy experts warn that the fallout of this ruling and possible appeal could still result in some Americans with HIV losing coverage. This could hinder their access to lifesaving antiretroviral therapy (ART), carrying serious implications for public health.

Congress gets to define ‘medically frail,’ not CMS​

Starting January 1, many adults must work or volunteer for 80 hours a month—or attend school or vocational training programs—to remain on Medicaid. Congress, however, exempted people who are medically frail from this mandate, which includes those with a "serious or complex medical condition."

HIV advocates and policy experts who previously spoke to CIDRAP News said they had taken solace in how Congress had crafted the exemption, since they assumed it meant people with HIV/AIDS wouldn't be subject to the work requirement mandate.

The exemption is important because Medicaid insures 46% of US residents with HIV/AIDS, according to an analysis of 2023 data published this summer by KFF, a nonpartisan health policy research nonprofit.

However, many balked when CMS released its interim final rule this summer, which said that, to qualify as medically frail, people had to show their diagnosis significantly impaired them—essentially that they were too sick or disabled to work.

This provision was vague and subjective, Amy Killelea, JD, an expert on HIV financing at Georgetown University's Center on Health Insurance Reforms, told CIDRAP News.

"[It] could have meant that even people who really should be exempt from work requirements would have a hard time documenting that part of the exemption test," Killelea said.

While Stearns' ruling provided a bit of a reprieve for the HIV/AIDS community, state Medicaid programs still must decide which conditions meet the definition of medically frail. It's expected that a number of states will include HIV/AIDS, partly because of the overall benefit to public health.

ART suppresses the amount of HIV in someone's blood to undetectable levels, thereby mitigating transmission of this communicable disease. When people with HIV lose Medicaid, it both harms their individual health and increases the likelihood of transmission to others.

"To destabilize Medicaid is a direct hit on any attempt to end the HIV epidemic in the United States," said Killelea.

Other provisions might still hinder ART access for Medicaid recipients​

The states that brought the suit also wanted Stearns to strike down the new CMS requirement that state Medicaid programs can consider only an enrollee's past claims and encounter data to determine whether they qualify as medically frail, and only if that documentation is from the past 12 months. And they opposed CMS limiting the number of times a state can accept someone self-attesting that they're medically frail to once per person per enrollment period.

Plaintiffs argued these rules were arbitrary and capricious, but Stearns wasn't sold.

"The Government provided a non-frivolous rationale for adopting each provision and explained why it did not find the States' concerns of disenrollment compelling," he wrote.

This part of the ruling is disappointing, because these rules will make it harder for people to qualify as medically frail, according to an analysis of the case from the Harvard Law School's Center for Health Law and Policy Innovation (CHLPI).

Limiting the evidence that states may consider increases administrative burdens on Medicaid members and their providers. So while the ruling is an overall step in the right direction, the new work requirement still creates barriers to care for people with HIV, Carmel Shachar, JD, MPH, one of the authors of CHLPI analysis, told CIDRAP News.

What comes next for Medicaid​

States had been planning for months to implement the now-struck-down CMS provision that had required them to determine whether an individual's health status was severe enough that they couldn't comply with the Medicaid work requirement. But as CHLPI notes, reverting back may not be so easy, especially since the mandate is slated to go into effect January 1.

Stearns did grant a six-month grace period from federal enforcement of medical frailty determinations to the states that brought the lawsuit. This gives them more time to iron out implementation, though it doesn't apply to states that didn't sue CMS.

CMS did not respond to CIDRAP News' request for comment; however, legal experts anticipate the federal government will appeal.

A similar case against CMS was recently filed by five Medicaid enrollees, six physician organizations, and the City of Columbus, Ohio, in the US District Court for the District of Maryland. How this case proceeds could further complicate implementation of the new Medicaid work requirements, with potential downstream effects for ART access.