Montana’s plan to expand Medicaid to the working poor is under the public magnifying glass starting Tuesday with the release of key documents needing federal approval.

The state plans to offer Medicaid to as many as 70,000 working Montanans who can't afford insurance but currently make too much to qualify for Medicaid. The proposal, known as the HELP Act, narrowly passed the Montana Legislature in April and contains a couple of curve balls that federal officials haven’t agreed to. The public will have 60 days to comment on those legislative twists before the paperwork requesting waivers to federal insurance requirements is mailed the Centers for Medicare and Medicaid Services in September.

The waivers are important to expanding Medicaid, a step that not only helps the uninsured, but also creates jobs, Gov. Steve Bullock said Tuesday.

“The HELP Act will not only save lives, but will also create jobs by bringing our tax dollars back from the federal government to extend health coverage,” Bullock said. “This draft waiver is an important step toward allowing Montanans to access coverage, while throwing a lifeline to Montana’s rural hospitals.”

Under the plan, Medicaid coverage would be offered to able-bodied adults earning up to $16,200 a year, or 138 percent of the federal poverty level. Those low-income participants would have to pay premiums equal to 2 percent of their personal income, something Montana insisted upon that the federal government doesn't require.

The second twist is a Montana requirement that a third party contractor administer the program.

Both of those caveats came from Republican lawmakers who demanded the working poor pay even a small amount so Medicaid wouldn’t be a total freebie and that business, not government manage Medicaid’s growth. The federal government will have to issue Montana a waiver for the state’s unusual requirements. If there’s no waiver, then there will be no Medicaid expansion.

Five other states with Republican legislatures have needed special approval before expanding their Medicaid programs. Officials for Montana’s Department of Public Health and Human Services said Monday they were confident their state would be the sixth.

The bigger concern, officials said, was timing. Open enrollment for subsidized health care begins Nov. 1 and lasts three months, and there are few exceptions. That signup clock will keep ticking for Montana’s working poor regardless of whether the state’s Medicaid expansion program is ready.

State officials say their goal is to launch the Medicaid expansion program by Nov. 1, which would enable new participants to sign up and begin receiving health insurance as early as January.

But there’s a lot of work of work to be done in the next four months, officials say. The state has to select a private contractor to run the expanded Medicaid system. It put the program out for bid July 1 and has set an Oct. 1 deadline for awarding a contract. A computer software program is needed to manage the passing of federal Medicaid funds from the state to the contractor, and eventually to doctors submitting bills for payment.

And then there are the required public comment periods. Montana law requires a 60-day public comment period before the waiver requests can be submitted to the federal government. The feds have their own 30-day comment period before approval can be granted to the state. The earliest the state can submit its waiver requests to the Centers for Medicare and Medicaid Services is Sept. 7. The earliest the federal government could begin ruling on the waiver is Oct. 8.

State health officials say there isn’t a lot of time to put all the pieces together, but that federal officials won’t be getting their first look of the Montana plan this fall.

Centers for Medicare and Medicaid Services followed Montana’s Medicaid expansion plans through the state Legislature. On Tuesday, when the waiver requests go public, CMS will begin perusing the documents informally as state residents begin the comment process.

Already, there are low-income Montanans lining up for Medicaid expansion. Many of them have never had insurance, said Barbara Schneeman communications director for Riverstone Health, public health care provider for Yellowstone County.

“The day the bill passed the Legislature, I messaged our staff to let them know. It hadn’t bee signed yet by the governor yet and people on our staff were already messaging me back asking, ‘How do I get people signed up?’” Schneeman, said. “We did an estimate last legislative session of the 20,000 people a year that we see. Nearly 8,000 of them would be eligible.”

Health care providers see another challenge in making the working poor aware that Medicaid expansion is available. The Legislature appropriated no money for promoting the program.

There’s also the challenge of fixing anything CMS rejects. State health officials say small changes are possible, but if major changes to Montana’s plan are required, the Legislature could have to be called back to Helena retool its Medicaid proposal.

Public meetings are scheduled for Billings on Aug. 18 and Helena on Aug. 20 so people can comment on the waivers. Information for commenting can be found at dphhs.mt.gov/medicaidexpansion.

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