Indiana initially implemented the ACA's Medicaid expansion through a Section 1115 waiver in February 2015. Indiana's waiver included important changes from federal law regarding enrollment and premiums. The initial waiver expired, and Indiana received approval for a waiver extension in February, 2018 which continues most components of HIP 2.0 and adds some new provisions related to enrollment and premiums. This brief looks at available data from the state's evaluation of premiums prepared by The Lewin Group (as well as other reporting to CMS) to highlight what is known about the impact of these policies to date. We review these data to identify potential implications for changes in the recent Indiana renewal and for other states considering similar provisions. Key findings include the following: (1) The state evaluation shows that more than half (55%) of all of those eligible to pay premiums under HIP 2.0 during the first two years of implementation failed to do so, resulting in negative consequences. (a) For those with incomes at or below 100% FPL, 57% or nearly 287,000 people were moved from a more comprehensive to a more limited benefit package for failing to pay a HIP 2.0 premium during the first two years of Indiana's waiver. (b) Among those with incomes above 100% FPL, over half (51%) of those determined eligible for HIP 2.0 did not make premium payments (over 46,000 people never enrolled in coverage because they never paid their first premium and another 13,550 people successfully enrolled in HIP 2.0 but later lost coverage for failing to pay a premium during the first two years of HIP 2.0). (2) The top two reasons cited by people who never enrolled in or lost HIP 2.0 coverage were affordability and confusion about the payment process. (3) Many people who never got or lost HIP 2.0 coverage for failing to pay a premium were uninsured. The data and findings have implications for the new provisions included in the Indiana renewal that include a tobacco premium surcharge, a lock-out for failure to timely renew and a work requirement. These changes could make premiums unaffordable for more individuals and result in potentially eligible people losing coverage. Recent quarterly reporting suggests that 28% of disenrollments were due to failure to complete or comply with redeterminations, so many could be subject to a coverage lock-out. These data as well as data about confusion in making premium payments could signal that administrative, paperwork or process barriers could affect individuals subject to new work requirements. Eligible individuals may experience problems in documenting their work status or navigating an exemption resulting in eligible individuals losing coverage. Understanding the implications of existing waiver policies in Indiana and tracking implications of the renewal policies could also help inform other states considering similar policies.
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