Painless” Administrative Ways For States To Preserve or Even
Increase ADAP Funding

by Thomas P. McCormack  (revised 12/23/04)

 

1.      Proactively Asking About and Paying Added Premiums for Offered, But Un-Taken-up,
Dependent Coverage in Employer Health Plans of Working Spouses and Domestic
Partners of Clients 

 

a. Working Spouses

 

While many if not most of those eligible for ADAP programs are

single, divorced or widowed, some are currently married. This therefore
means that married clients who have working age spouses---even though they
may well be small minority of the caseload---need detailed attention to uncover

possible un-taken-up dependent coverage in spouses’ job health plans.

A number of key studies of health insurance enrollment show conclusively
that lower income workers are highly unlikely to enroll their dependents
in their job health plans. (Some of these studies are available on request;
however, they are long, detailed, technical and hard to plow through!) This
is because, for almost all employer-based plans, the employee must bear a
costly premium surcharge to enroll his dependents. For most of those
making, say, $10 an hour or less (e.g., WalMart clerks, etc.) this is simply
unaffordable---even if they have seriously ill dependents. After all, food
and shelter come first at this income level.

 

For example, in a survey released in September,2003, the Kaiser Family

Foundation found that only 33% of employees chose to take family coverage

through their company in 2003, down from 39% in 2001. In addition, the

percentage of companies that fully subsidize family health  premiums

decreased to 15% in 2003 from 27% in 2001, the survey found. Premiums

for family coverage rose 49% since 2000---with much of the surcharge to add

coverage of  dependent family members being deducted out of employee

paychecks, except  for the most progressive employers. The Bureau of Labor

Statistics reported that same month that employees must pay an average of over

$228 monthly as payroll deductions to secure dependent coverage. This means

that a large percentage of spouses eligible to get dependent coverage in a

working spouse’s job health plan don’t get enrolled by their employed spouse.

 

So this phenomenon means that---even if the ADAP program asks about
other possible health insurance (e.g., which covers drugs) on its application
forms---such patients will (somewhat misleadingly) answer that they have
no such coverage (because they're not enrolled now, because they've
forgotten a prior decision not to enroll and/or because the employed spouse
didn't share the decision to non-enroll with the spouse on the public health
program). So, to find out if an employer plan with offered dependent coverage
is available from a working spouse's employer will require careful and
precise telephoned or mailed questions to the program applicant, his or
her spouse and even to the spouse's employer's benefits office.

One way to begin to deal with this might be to have the program's
enrollment/eligibility/systems staff produce a list of those cases with
spouses who've reported earned income. (In all states, for programs
determining eligibility on family income, some data is kept on who has what
sort of income). Such cases might then receive a mailing asking for the name
and telephone number of the working spouse's employer---with follow up
correspondence to the employer to inquire if there's a health plan, the
premium surcharge amount, the date of the next Open Season and the
plan's benefit package. Where a pre-existing condition waiting period
has to be "waited out"---and, of course, this is far more rare than before
thanks to the HIPPA legislation---cases would have to be monitored/diaried.
And all cases requiring premium payments and related monitoring/diarying
would obviously entail some added administrative effort.

However, such an extra effort to uncover non-election of offered employer
health insurance should prove well worthwhile: The figures cited in the
studies mentioned above all suggest that not just a large number--but an
absolute majority-- of couples with a working spouse in ADAP’s income
range have declined offered dependent coverage in health plans due to cost.

 

b. Health Insurance As Dependent of  Working Domestic Partner

For ADAP, but not Medicaid, there's still another group of dependents
of workers whose health insurance premiums can be paid by state Ryan White
programs as a tool to stretch limited funds. These are those clients living
with domestic partners who are working for employers which permit enrollment
of such partners in the employer health plan. These are mostly gay
couples; but there are probably numbers of straight unmarried couples too.

At www.hrc.org , at the "worknet" and then the "domestic partner" icons,
are listed the 9 states, 136 or more localities and many but not all of
those enlightened private employers that offer their employees the right to
enroll their domestic partners in employer group health plans. There's even
a query function to find out about particular employers as well as a "2002:
State of the Workplace" report offering even more updated information about
domestic partner health insurance offerings by progressive employers.
Also see the list at http://www.buddybuddy.com/d-p-1.html , dated 9/ 2002.

As with traditional working spouses, lower-paid domestic partners may not
have been able to afford to enroll their HIV+ partners (i.e., ADAP clients) in
the workplace health plan. But even higher income ones may not have been
aware that the benefit is available---or simply viewed enrolling in ADAP (at
a big cost to ADAP's budget but not their own !) as more convenient for
them than enrolling in the employer plan.

Obviously , screening an ADAP caseload and new applicants for this type
of possible alternate coverage will be even more labor-intensive than
screening those with traditional working spouses. ADAP enrollees and
applicants must be asked whether they have live-in domestic partners; if
such partners are working; where they're working; whether the employer
offers domestic partner health coverage; and what the plan premiums,
coverage and enrollment details are. As with traditional employed spouses,
this information might well also require directly contacting partners' job
benefits offices to secure details and arrange premium payment and
enrollment. In some cases, partners' sensitivities to contacting the
workplace must be accommodated too.

Since ADAP enrollees and applicants with live-in domestic partners probably
outnumber those with traditional (straight) working spouses, this will be a new

a new---even if hard-to-develop---alternate health coverage source.

 

c. Figures on dependent enrollment for low income workers

 

US	All US Adults, Access Through Other Than Own Employer
US	ALL RACES	Total	No Access	With Access Thru Any Fam Member	With Access Other Than Thru Own Employer	No Employer Coverage	With Coverage, But Not Thru Own-Employer	Non-Own-Er Take-Up Rate	Check Diff
US	TOTAL	158,747,266	44,184,350	114,562,916	42,537,081	13,100,216	29,436,865	69.2%
US	ROW PCT	100.0%	27.8%	72.2%	26.8%	8.3%	18.5%	69.2%
US	Gross Family Income as % FPG	Total	No Access	With Access Thru Any Fam Member	With Access Other Than Thru Own Employer	No Employer Coverage	With Coverage, But Not Thru Own-Employer	Non-Own-Er Take-Up Rate
US	< 100%	22,565,735	17,664,512	4,901,224	2,810,532	1,987,418	823,114	29.3%	0.0000
US	100% - 132%	8,325,965	4,785,260	3,540,705	1,615,353	1,073,170	542,184	33.6%	0.0000
US	133% - 199%	18,481,084	6,494,353	11,986,731	4,946,417	2,531,558	2,414,859	48.8%	(0.0000)
US	200% - 249%	12,684,809	3,116,622	9,568,187	3,753,184	1,385,700	2,367,484	63.1%	0.0000
US	250% - 399%	39,167,139	6,034,138	33,133,001	11,500,455	3,205,224	8,295,231	72.1%	0.0000
US	400% +	57,522,533	6,089,465	51,433,068	17,911,139	2,917,147	14,993,992	83.7%	0.0000
US	Check Diff	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000
US	Gross Family Income as % FPG	Total	No Access	With Access Thru Any Fam Member	With Access Other Than Thru Own Employer	No Employer Coverage	With Coverage, But Not Thru Own-Employer	Non-Own-Er Take-Up Rate
US	< 100%	100.0%	78.3%	21.7%	12.5%	8.8%	3.6%	29.3%
US	100% - 132%	100.0%	57.5%	42.5%	19.4%	12.9%	6.5%	33.6%
US	133% - 199%	100.0%	35.1%	64.9%	26.8%	13.7%	13.1%	48.8%
US	200% - 249%	100.0%	24.6%	75.4%	29.6%	10.9%	18.7%	63.1%
US	250% - 399%	100.0%	15.4%	84.6%	29.4%	8.2%	21.2%	72.1%
US	400% +	100.0%	10.6%	89.4%	31.1%	5.1%	26.1%	83.7%
US	ROW PCT	100.0%	27.8%	72.2%	26.8%	8.3%	18.5%	69.2%
US	Gross Family Income as % FPG	Total	No Access	With Access Thru Any Fam Member	With Access Other Than Thru Own Employer