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Policy Update – Employment, Health Care and Disability - February 2014

Policy Update – Employment, Health Care and Disability - February 2014 Newsletter

February 27, 2014

The LEAD Center Policy Update – Employment, Health Care and Disability is a project of the LEAD Center in collaboration with the Autistic Self Advocacy Network.

The Office of Disability Employment Policy (ODEP), an office within the U.S. Department of Labor, has issued a policy brief on the importance of health care in improving employment outcomes for youth and young adults with chronic health conditions or other disabilities. The policy brief details the results of a 2012 study on health care transition, which included a review of state health care, education, vocational rehabilitation and other systems that interacted with youth and young adults with disabilities. The study concludes that, in order to join the workforce successfully, youth with chronic health conditions and disabilities need coordinated transition planning to ensure that they retain access to quality health care upon reaching adulthood. Lack of coordination between healthcare providers and education systems, inconsistent access to healthcare services and financial pressure on families constitute significant barriers to coordinated transition planning and, as a result, to workforce participation. The Patient Protection and Affordable Care Act of 2010 (ACA), which expands access to health insurance and creates incentives for care coordination by healthcare providers, may help address some of these barriers. ODEP concludes by recommending increased education and outreach to youth, families and other caring adults about the importance of transition planning, as well as increased professional development and education of health care and youth service providers on transition planning. The full ODEP report is available online.


In states that have expanded Medicaid coverage to all adults with incomes under 133 percent of the federal poverty level (FPL), pursuant to the ACA, individuals with incomes close to 133 percent of FPL may experience changes in the source of their health coverage as their income rises and falls. During months that they earn less than 133 percent of FPL, these individuals will be covered by Medicaid. During months that they earn more than 133 percent of FPL, they may lose eligibility for Medicaid. Before the rollout of statewide health insurance exchanges in January 2014, these individuals may have become uninsured altogether; now, however, they may purchase private health insurance through the statewide health insurance exchanges and receive tax credits to help offset the cost of premiums.

State and policy experts are now considering ways to reduce the impact of repeated transfers between Medicaid and private health insurance coverage, known as “churning.” Churning may pose special challenges to workers with disabilities or complex health conditions who require a consistent and uninterrupted plan of care but may be at risk of losing health care coverage for unspecified periods of time due to fluctuation in hours worked or wages earned.

Several states are attempting to proactively address threats of churning as they roll out their expanded Medicaid eligibility:

  • In Nevada, Medicaid managed-care companies will be required to offer a similar plan on the statewide health insurance exchanges, so that Medicaid enrollees who begin earning more than 133 percent of FPL will be able to retain comparable coverage;
  • In Washington state, health insurance companies that offer plans on the statewide exchanges will receive incentives to offer their plans to Medicaid enrollees, so that Medicaid enrollees can keep the same plan as their income rises;
  • In Delaware, plans offered on the statewide exchanges will be required to provide continued coverage of previously approved services and medications for individuals transitioning off of Medicaid;
  • In Congress, a bill sponsored by House Representatives Gene Green (D-Texas) and Joe Barton (R-Texas) will, if passed, guarantee 12 months of continuous eligibility to people enrolled in Medicaid.

Further coverage is available via the Washington Post. cf858d7e-73fa-11e3-8def-a33011492df2_story.html

The Congressional Budget Office (CBO) has issued a report estimating the effect of the Affordable Care Act on the labor market through 2024. The CBO predicted that, overall, Americans will work 1.5-2 percent fewer hours between 2017 and 2024 than they would in the absence of the Affordable Care Act. This reduction will result from decreased dependence on employers as a source of health coverage. Further, some people may choose to work part-time or retire early, given that they may now purchase health insurance through statewide marketplaces and the ACA provides health insurance premium subsidies to people earning below 600 percent of the federal poverty level who do not have access to employer-sponsored insurance.

The CBO also, however, predicted that some workers who previously relied on Medicaid will be free to work more hours. Some of these workers – including people with disabilities who rely on Medicaid coverage through the Supplemental Security Income (SSI) program – may have been required to limit the hours that they worked in order to stay under the previous income threshold for Medicaid eligibility. In states that expand Medicaid eligibility to all adults with incomes below 133 percent of FPL, these workers will be able to earn up to that limit while maintaining access to Medicaid, and workers in all states will be able to earn up to 400 percent of the FPL and receive tax subsidies to offset the cost of private insurance. The full CBO report is available online., pp. 117-127.

The National Disability Navigator Resource Collaborative has issued a guide for healthcare insurance marketplace Navigators on how to assist people with disabilities in obtaining private health insurance. The Affordable Care Act, which created new statewide marketplaces where individuals can purchase health insurance coverage, requires that these Navigators be available free of charge to help people evaluate health plans and select a plan that suits their needs. The Guide to Disability for Healthcare Insurance Marketplace Navigators includes information on disability etiquette, accommodations that people with disabilities may need when seeking information about health insurance options, and how to identify and address the specific needs of people with disabilities with respect to their health coverage. The guide also addresses issues such as ensuring that people with disabilities maintain access to specialists or other providers with whom they have important preexisting relationships, helping people with disabilities choose a plan that covers specific services that they need and evaluating whether people with disabilities are eligible for Home and Community-Based Services (HCBS) through Medicaid. The guide is available via the National Disability Navigator Resource Collaborative website.

A review of the evidence on supported employment for people with psychiatric disabilities shows that supported employment services lead to higher rates of competitive employment, faster job placement, higher wages and increases in hours and weeks on the job, according to a recent article published in Psychiatric Services. The review, sponsored by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), encompassed 12 systematic reviews of supported employment programs and 17 randomized controlled trials. A summary of the study is available online.

On January 6, the U.S. Department of Justice issued a report detailing its findings after an investigation of Rhode Island’s system of providing employment and vocational services to people with intellectual and developmental disabilities. The report concluded that Rhode Island’s reliance on segregated day programs, including sheltered workshops that employ exclusively people with disabilities, violated the Americans with Disabilities Act’s (ADA’s) requirement that states provide services to people with disabilities in the most integrated setting appropriate to their needs. The Department of Justice recommended that, in order to comply with the ADA’s integration requirements, Rhode Island increase access to services, such as supported employment, that enable people with intellectual and developmental disabilities to work in competitive, integrated environments. The state must also develop a plan to transition individuals currently in segregated settings toward integrated employment and to provide individuals with intellectual and developmental disabilities with information about their right to continued Medicaid coverage, such as that available through the state’s Medicaid Buy-In program, while working. The full Department of Justice report is available online.

On February 1, Kansas began providing long-term supports and services (LTSS) to people with developmental disabilities through its Medicaid managed care program, KanCare. In December 2013, after delaying the move for one year, the Centers for Medicare and Medicaid Services (CMS) had delayed the transition to KanCare for an additional month, citing continued concerns about the effect of the transition on continuity of care and on waiting lists for services. On January 29, 2014, CMS issued a letter approving the Kansas transition to managed care for LTSS for people with developmental disabilities. As a condition of approval, Kansas will be required to provide LTSS to 1,400 previously underserved individuals and improve its reporting of services provided to people with developmental disabilities. Kansas will also be required to use some its savings from the transition to managed care to improve access to community-based LTSS. Employment in competitive integrated settings will be one of the metrics that Kansas will use to evaluate the performance of the managed care organizations that provide LTSS to people with intellectual and developmental disabilities enrolled in KanCare.

The National Council on Disability (NCD), an independent board that advises the president on disability issues, had written to CMS in December and in mid-January urging it to require specific assurances from Kansas that, among other things, the transition to managed care would involve input from stakeholders, would address the needs of currently underserved individuals, and would not result in loss of services or increases in institutionalization of people with developmental disabilities.

• View CMS’ letter approving the transition to KanCare.

• View NCD’s January 14, 2014 letter to CMS.

Please note: The PDF generated using this link is not 508-compliant and is provided as a courtesy for those who wish to print the material. For a fully accessible version of this newsletter, please read the web-based version.