Hospital waiting room (photo by Dept. of Foreign Affairs and Trade [CC BY 2.0] via Wikimedia Commons)
Hospital waiting room (photo by Dept. of Foreign Affairs and Trade [CC BY 2.0] via Wikimedia Commons)

Starting January 1, 2019, most adults covered by Medicaid will be required to pay a copayment for most Medicaid-covered services. It’s a policy in search of a constituency, and Kentuckians deserve to know why.

First, some basics of the copay policy

The copays will range from $3 for most office visits to $50 for hospital stays. It may not sound like much to some people, but for households on very limited budgets or for people with chronic health conditions, this presents real tradeoffs.

Fourteen years of research tells us that even modest copays cause people to either ration their care (fewer visits or choosing which prescriptions to fill), or take resources away from necessities like food, housing, and utilities. Either option is a risky proposition. Even adults who would be deemed “medically frail” and exempt from the upcoming Medicaid waiver’s most punitive measures will be required to pay copays under this policy.

Copays will discourage people from seeking care

The policy dictates that adults making less than 100% of poverty cannot be turned away from services or prescriptions because they can’t pay their copay. In reality, however, it’s unlikely that providers will always know how these rules work. The mere existence of the copay will discourage some patients from seeking care. And when beneficiaries access services for which they cannot pay, the cost burden is shifted to Medicaid providers in the form of reduced reimbursements for services, further straining the health care safety net for Kentucky’s poorest residents. Imagine that scene happening over and over—someone who can’t afford to pay being forced to say so every time they see a provider.

So who’s asking for these new copays?

So who wants this policy?

  • Certainly not the providers, who will face more administrative hurdles and reduced reimbursements.
  • Nor the Managed Care Organizations responsible for paying claims, which already have the authority to charge copays, but have chosen to waive them (probably for some or all the reasons listed above).
  • Copays don’t benefit Medicaid beneficiaries who will ultimately face either reduced access to care—leading to more expensive care later—or financial hurdles.
  • And, there’s no legal requirement forcing the state to do this; states have the option to do this or not.

So the real question is: why?

Is it an attempt to sell the Medicaid waiver?

On the horizon is the planned implementation of the Kentucky HEALTH Medicaid waiver. It’s supposed to start on April 1st, and its requirements, penalties, bonus points, and reduced benefits have been well-documented.

The state says these new copay requirements are not related; it’s a totally separate policy that has nothing to do with the waiver. Or is it? Think of the major policy swings in just a short time, especially for such a large program.

Right now, no one pays copayments. Starting January 1st, almost everyone does. Then, if the waiver kicks in on April 1st, some can pay premiums instead of copays, and some will be exempt from both because of their medically frail status, although it’s still a net loss—for everyone—due to the red tape involved and the certainty of large numbers of people losing coverage.

So, are the copay and waiver policies truly unrelated? Technically, yes. However, during recent meetings, the administration has presented copays as something they are being forced to charge until the waiver is implemented. Yes, they concede, copays may cause a lot of heartburn for everyone. But under the Kentucky HEALTH waiver, beneficiaries can pay premiums instead of copays, and the medically frail don’t have to pay anything. Therefore, they ask, doesn’t Kentucky HEALTH looks like a better deal?

For those designated medically frail (a process that still needs work), maybe it is. But a cynical person might conclude this is just the beginning of a campaign to divide and conquer, drumming up support for a harsh Medicaid waiver by setting up a false dilemma between the copays and the premiums.

We need the truth … and we need a third option

What everyone deserves to know is the real reason why we need to implement the copay policy right now. Is there any real benefit to the program, its beneficiaries, our Medicaid providers, and the Commonwealth as a whole? If there is, put forth the evidence.

But let’s be clear: Both the copay policy and the waiver are choices the state is making. We should insist on a third choice: none of the above.


Jason Dunn, policy analyst for Kentucky Voices for Health (photo provided by KVH)
Jason Dunn, policy analyst for Kentucky Voices for Health (photo provided by KVH)

Written by Jason Dunn, Policy Analyst, Kentucky Voices for Health