June 29, 2004
The Honorable Tommy G. Thompson
Secretary of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Secretary Thompson:
As members of the Consortium for Citizens with Disabilities (CCD), we are writing to express our concerns with a proposal by the State of Florida to privatize the eligibility determination process for Medicaid on a statewide basis.
The CCD is a coalition of national organizations advocating for self-determination, independence, empowerment, integration and inclusion of children and adults with disabilities in all aspects of society. We represent individuals facing a wide range of challenges including mental illness, epilepsy, physical disabilities, and mental retardation.
Medicaid is a lifeline for millions of people with disabilities, providing critically needed services and supports to individuals who do not have access to affordable private coverage or have health care needs that extend beyond the coverage typically provided by private insurance plans. We are increasingly concerned about recent state actions to scale back Medicaid coverage and eligibility as well as Federal initiatives to encourage states to use section 1115 waiver authority to further restrict coverage.
The waiver proposal submitted by Florida on April 23rd, 2004 is especially troubling as it would likely result in individuals with disabilities, in particular, not receiving Medicaid coverage to which they are entitled. Under this waiver, private vendors would receive a fixed sum in payment for providing enrollment services for Medicaid beneficiaries. We are concerned that the profit motive of private contractors may naturally lead them to try to limit the enrollment services they provide rather than providing the extra attention some individuals with disabilities may need to successfully enroll in the Medicaid program. The waiver application fails to include any assurances that individuals with disabilities, who may have more complex needs than other Medicaid enrollees, will receive the additional services necessary for them to successfully enroll. Additionally, the waiver proposal does not even specify that the enrollment of all eligible individuals would be a key function of a contract awardee which leads us to question whether this proposal is really intended to be a back-door way to limit eligibility without paying the political consequences.
What will happen if a private contractor finds that the lump sum payment is not adequate to cover the cost of enrolling all of those eligible for Medicaid? We are concerned that services that are most advantageous to people with disabilities may be the first to go and/or that enrollment operations in general would be slowed to a standstill. This waiver application fails to demonstrate that the state would establish adequate safeguards to protect against this outcome.
The state also fails to adequately demonstrate how it would ensure accessibility to enrollment processes if a private vendor was unable to carry out a contract to provide eligibility services. In particular, the state should show how it would minimize the confusion and additional burdens that this kind of disruption would cause for Medicaid beneficiaries, particularly those already struggling with the added challenges that disabilities often present.
This waiver proposal would allow private contractors to significantly change the state’s current enrollment system, including by closing existing offices and instead using kiosks in public places or the Internet to enroll beneficiaries. These changes will cause considerable confusion among beneficiaries and also raise significant accessibility issues for people with disabilities and could violate the Americans with Disabilities Act (ADA). As you know, the ADA requires that state governments and private entities that contract with them ensure that communications with individuals with disabilities, including those sensory impairments are as effective as communications with others (28 C.F.R. 35.160 (a)). To be equally effective the communication must be provided in a manner that is comparable (e.g. in terms of convenience) to that provided to non-disabled individuals and it must work. Neither the ADA Standards for Accessible Design, nor the proposed revised ADA Accessibility Guidelines, contain specific requirements for making kiosks or the Internet accessible to individuals with sensory and other disabilities. We therefore believe it is imperative for the State of Florida to demonstrate specifically how it will meet the ADA’s effective communication requirements.
Florida has proposed establishing private-run eligibility services on a statewide basis. In light of the very significant concerns raised by this change to enrollment processes, it should, at the very least, be tested in a more limited fashion first, e.g., in one or two counties.
Moreover, the application lacks adequate detail regarding how an evaluation of this privatization effort would be conducted. Substantial resources and strict federal oversight must be devoted to ensuring a fair and independent analysis of the impact this initiative would have. We urge you to require that the impact on people with disabilities be a special focus of this evaluation.
Given the critical nature of the safety net that Medicaid provides for people with disabilities, these issues must be comprehensively addressed before this highly risky change to Medicaid law is authorized. Thank you very much for your consideration of our views.
Sincerely,
Alexander Graham Bell Association for the Deaf and Hard of Hearing
American Association of People with Disabilities
American Association on Mental Retardation
American Council of the Blind
American Foundation for the Blind
American Medical Rehabilitation Providers Association
American Physical Therapy Association
Association for Education and Rehabilitation of the Blind and Visually Impaired
Association of Maternal & Child Health Programs
Association of University Centers on Disabilities
Bazelon Center for Mental Health Law
Brain Injury Association of America
Easter Seals
Helen Keller National Center
Lutheran Services in America
National Association of Councils on Developmental Disabilities
National Association of Protection and Advocacy Systems
National Association of Social Workers
National Coalition on Deaf-Blindness
National Council for Community Behavioral Healthcare
National Down Syndrome Congress
National Mental Health Association
National Organization of Social Security Claimants’ Representatives
National Rehabilitation Association
Spina Bifida Association of America
The Arc of the United States
United Cerebral Palsy
United Spinal Association
Volunteers of America
cc: Dr. Mark McClellan, Administrator, Centers for Medicare and Medicaid Services
Dennis Smith, Director, Center for Medicaid and State Operations
Contact: Kirsten Beronio (National Mental Health Association ) 202-675-8413 or Liz Savage (The Arc and UCP Public Policy Collaboration) 202-783-2229