Monthly Archives: June 2019

10 Facts Funeral Directors Don’t Want You to Know

June 4, 2019

Funerals are among the most expensive purchases many consumers will ever make, ranking only behind the purchase of a home and an automobile. A traditional funeral, including a casket and vault, can start at around $7,000, although “extras” like flowers, obituary notices, acknowledgment cards or limousines can add thousands of dollars to the bottom line. Many funerals run well over $10,000.

But it’s possible to spend much less if you don’t let funeral directors pressure you into buying goods or services you don’t want or need. To help consumers resist such pressure and become more informed, Bankrate.com has compiled a list of “10 things funeral directors don’t want you to know.” The list is summarized below:

  1. Shopping around for funeral services can save you thousands of dollars.
  2. Funeral directors are not clergy. Although consumers tend to trust them implicitly and believe everything they say, it is well to remember that funeral homes are in business to make money.
  3. Embalming is rarely required when the person will be buried within 24 to 48 hours.
  4. Seeing your loved one prior to burial without the benefit of embalming will not leave you with unresolved grief issues. “If more people knew what embalming entailed, they would not choose to do it,” says Joshua Slocum, executive director of the Vermont-based Funeral Consumers Alliance, a not-for-profit consumer information and advocacy group.
  5. Sealed caskets, which add considerable cost, cannot preserve a body.
  6. A funeral provider may not refuse or charge a fee to handle a casket you bought elsewhere.
  7. You don’t need to spend more than $400 to $600 for a modest casket.
  8. You do not have to buy the funeral home’s entire package of services. You may pick and choose the services you want.
  9. You can plan and carry out many things on your own to honor your loved one without paying for services from a funeral home.
  10. Local funeral and memorial societies can help consumers find ethical establishments and often negotiate discounts for their members. For example, the Funeral Consumers Alliance has 115 chapters in 46 states around the country.

All funeral homes must comply with the Federal Trade Commission’s Funeral Rule. The Funeral Rule requires all funeral homes to supply customers with a general price list that details prices for all possible goods or services. The rule also stipulates what kinds of misrepresentations are prohibited and explains what items consumers cannot be required to purchase, among other things. For more on the rule, click here.

For the FTC’s series of articles on Shopping for Funeral Services, click here.

Maximizing Social Security Survivor’s Benefits

June 4, 2019

Social Security survivor’s benefits provide a safety net to widows and widowers. But to get the most out of the benefit, you need to know the right time to claim.

While you can claim survivor’s benefits as early as age 60, if you claim benefits before your full retirement age, your benefits will be permanently reduced. If you claim benefits at your full retirement age, you will receive 100 percent of your spouse’s benefit or, if your spouse died before collecting benefits, 100 percent of what your spouse’s benefit would have been at full retirement age. Unlike with retirement benefits, delaying survivor’s benefits longer than your full retirement age will not increase the benefit. If you delay taking retirement benefits past your full retirement age, depending on when you were born your benefit will increase by 6 to 8 percent for every year that you delay up to age 70, in addition to any cost of living increases.

You cannot take both retirement benefits and survivor’s benefits at the same time. When deciding which one to take, you need to compare the two benefits to see which is higher. In some cases, the decision is easy—one benefit is clearly much higher than the other. In other situations, the decision can be a little more complicated and you may want to take your survivor’s benefit before switching to your retirement benefit.

To determine the best strategy, you will need to look at your retirement benefit at your full retirement age as well as at age 70 and compare that to your survivor’s benefit. If your retirement benefit at age 70 will be larger than your survivor’s benefit, it may make sense to claim your survivor’s benefit at your full retirement age. You can then let your retirement benefit continue to grow and switch to the retirement benefit at age 70.

Example: A widow has the option of taking full retirement benefits of $2,000/month or survivor’s benefits of $2,100/month. She can take the survivor’s benefits and let her retirement benefits continue to grow. When she reaches age 70, her retirement benefit will be approximately $2,480/month, and she can switch to retirement benefits. Depending on the widow’s life expectancy, this strategy may make sense even if the survivor’s benefit is smaller than the retirement benefit to begin with.

Keep in mind that divorced spouses are also entitled to survivor’s benefits if they were married for at least 10 years. If you remarry before age 60, you are not entitled to survivor’s benefits, but remarriage after age 60 does not affect benefits. In the case of remarriage, you may need to factor in the new spouse’s spousal benefit when figuring out the best way to maximize benefits.

How to Fight a Nursing Home Discharge

June 4, 2019

Once a resident is settled in a nursing home, being told to leave can be very traumatic. Nursing homes are required to follow certain procedures before discharging a resident, but family members often accept the discharge without questioning it. Residents can fight back and challenge an unlawful discharge.

According to federal law, a nursing home can discharge a resident only for the following reasons:

  • The resident’s health has improved
  • The resident’s needs cannot be met by the facility
  • The health and safety of other residents is endangered
  • The resident has not paid after receiving notice
  • The facility stops operating

Unfortunately, sometimes nursing homes want to get rid of a resident for another reason–perhaps the resident is difficult, the resident’s family is difficult, or the resident is a Medicaid recipient. In such cases, the nursing home may not follow the proper procedure or it may attempt to “dump” the resident by transferring the resident to a hospital and then refusing to let the him or her back in.

If the nursing home transfers a resident to a hospital, state law may require that the nursing home hold the resident’s bed for a certain number of days (usually about a week). Before transferring a resident, the facility must inform the resident about its bed-hold policy. If the resident pays privately, he or she may have to pay to hold the bed, but if the resident receives Medicaid, Medicaid will pay for the bed hold. In addition, if the resident is a Medicaid recipient the nursing home has to readmit the resident to the first available bed if the bed-hold period has passed.

In addition, a nursing home cannot discharge a resident without proper notice and planning. In general, the nursing home must provide written notice 30 days before discharge, though shorter notice is allowed in emergency situations. Even if a patient is sent to a hospital, the nursing home may still have to do proper discharge planning if it plans on not readmitting the resident. A discharge plan must ensure the resident has a safe place to go, preferably near family, and outline the care the resident will receive after discharge.

If the nursing home refuses to readmit a patient or insists on discharging a resident, residents can appeal or file a complaint with the state long-term care ombudsman. The resident should appeal as soon as possible after receiving a discharge notice or after being refused readmittance to the nursing home. You can also require the resident’s doctor to sign off on the discharge. Contact your attorney to find out the best steps to take.

For more on protecting the rights of nursing home residents, see the guide 20 Common Nursing Home Problems–and How to Resolve Them by Justice in Aging.

What’s a Health Care Proxy and Why Do I Need One?

June 4, 2019

If you become incapacitated, who will make your medical decisions? A health care proxy allows you to appoint someone else to act as your agent for medical decisions. It will ensure that your medical treatment instructions are carried out, and it is especially important to have a health care proxy if you and your family may disagree about treatment. Without a health care proxy, your doctor may be required to provide you with medical treatment that you would have refused if you were able to do so.

In general, a health care proxy takes effect only when you require medical treatment and a physician determines that you are unable to communicate your wishes concerning treatment. How this works exactly can depend on the laws of the particular state and the terms of the health care proxy itself. If you later become able to express your own wishes, you will be listened to and the health care proxy will have no effect.

If you are interested in drawing up a health care proxy document, contact your attorney.

Medicare Beneficiaries Need to Know the Difference Between a Wellness Visit and a Physical

June 4, 2019

ELA News:

Medicare covers preventative care services, including an annual wellness visit. But confusing a wellness visit with a physical could be very costly.

As part of the Affordable Care Act, Medicare beneficiaries receive a free annual wellness visit. At this visit, your doctor, nurse practitioner or physician assistant will generally do the following:

  • Ask you to fill out a health risk assessment questionnaire
  • Update your medical history and current prescriptions
  • Measure your height, weight, blood pressure and body mass index
  • Provide personalized health advice
  • Create a screening schedule for the next 5 to 10 years
  • Screen for cognitive issues

You do not have to pay a deductible for this visit. You may also receive other free preventative services, such as a flu shot.

The confusion arises when a Medicare beneficiary requests an “annual physical” instead of an “annual wellness visit.” During a physical, a doctor may do other tests that are outside of an annual wellness visit, such as check vital signs, perform lung or abdominal exams, test your reflexes, or order urine and blood samples. These services are not offered for free and Medicare beneficiaries will have to pay co-pays and deductibles when they receive a physical. Kaiser Health News recently related the story of a Medicare recipient who had what she assumed was a free physical only to get a $400 bill from her doctor’s office.

Adding to the confusion is that when you first enroll, Medicare covers a “welcome to Medicare” visit with your doctor. To avoid co-pays and deductibles, you need to schedule it within the first 12 months of enrolling in Medicare Part B. The visit covers the same things as the annual wellness visit, but it also covers screenings and flu shots, a vision test, review of risk for depression, the option of creating advance directives, and a written plan, letting you know which screenings, shots, and other preventative services you should get.

To avoid receiving a bill for an annual visit, when you contact your doctor’s office to schedule the appointment, be sure to request an “annual wellness visit” instead of asking for a “physical.” The difference in wording can save you hundreds of dollars. In addition, some Medicare Advantage plans offer a free annual physical, so check with your plan if you are enrolled in one before scheduling.

How To Find And Use New Federal Ratings For Rehab Services At Nursing Homes

June 4, 2019

NAELA News:

For the first time, the federal government is shining a spotlight on the quality of rehabilitation care at nursing homes — services used by nearly 2 million older adults each year.

Medicare’s Nursing Home Compare website now includes a “star rating” (a composite measure of quality) for rehab services — skilled nursing care and physical, occupational or speech therapy for people recovering from a hospitalization. The site also breaks out 13 measures of the quality of rehab care, offering a more robust view of facilities’ performance.

Independent experts and industry representatives welcomed the changes, saying they could help seniors make better decisions about where to seek care after a hospital stay. This matters because high-quality care can help older adults regain the ability to live independently, while low-quality care can compromise seniors’ recovery.

“It’s a very positive move,” said David Grabowski, a professor of health care policy at Harvard Medical School. He noted that previous ratings haven’t distinguished between two groups in nursing homes with different characteristics and needs — temporary residents getting short-term rehabilitation and permanent residents too ill or frail to live independently.

Temporary residents are trying to regain the ability to care for themselves and return home as soon as possible, he noted. By contrast, permanent residents aren’t expecting improvements: Their goal is to maintain the best quality of life.

Three separate ratings for the quality of residents’ care now appear on the Nursing Home Compare website: one for overall quality (a composite measure); another one for “short-stay” patients (people who reside in facilities for 100 days or less, getting skilled nursing services and physical, occupational or speech therapy) and a third for “long-stay” patients (people who reside in facilities for more than 100 days).

Ratings for short-stay patients — available for 13,799 nursing homes — vary considerably, according to a Kaiser Health News analysis of data published by the government in late April. Nationally, 30% of nursing homes with a rating received five stars, the highest possible. Another 21% got a four-star rating, signifying above-average care. Twenty percent got three stars, an average performance. Seventeen percent got two stars, a worse-than-average score. And 13% got one star, a bottom-of-the-barrel score. (Altogether, 1,764 nursing homes did not receive ratings for short-stay patients.)

Here’s information about how to find and use the new Nursing Home Compare data, as well as insights from Kaiser Health News’ analysis:

Finding data about rehabilitation. Enter your geographic location on Nursing Home Compare’s home page, and a list of facilities will come up. You can select three at a time to review. Once you’ve done so, hit the “compare now” button at the top of the list. (To see more facilities, you’ll need to repeat the process.)

A new page will appear with several tabs. Click on the one marked “quality of resident care.” The three overall star ratings described above will appear for the facilities you’ve selected.

Below this information, two options are listed on the left side: “short-stay residents” and “long-stay residents.” Click on “short-stay residents.” Now you’ll see 13 measures with actual numbers included (most but not all of the time), as well as state and national averages.

Understanding the star rating. Six measures are used to calculate star ratings for the quality of rehab care for short-stay patients. Two of them concern emergency room visits and rehospitalizations, potential indicators of problematic care. Another two examine how well pain was controlled and bedsores were managed. One measure looks at how many patients became better able to move around on their own, an important element of recovery. Yet another examines the rate at which antipsychotic medications were newly prescribed. (These drugs can have significant side effects and are not recommended for older adults with dementia.)

One measure of great interest to seniors is the percentage of residents who return successfully home after a short nursing home stay. But actual numbers aren’t available on the Nursing Home Compare website this time around: Instead, facilities are listed as below average, average or above average. The national average, reported in April, was 48.6%, indicating room for improvement.Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

Tracking variations in performance. Some facilities outperform others by large margins on measures of quality of care for short-stay residents. And some facilities have high scores in some areas, but not in others.

For instance, the nursing home at Westminster Village, a high-end continuing care retirement community in Scottsdale, Ariz., had the highest score for rehospitalizations — 39.9% — out of 68 facilities in and around Phoenix. (By contrast, the lowest score in the Phoenix area was 15.4% and the state average was 23.5%.) It also had the highest rate of helping residents improve their ability to move around on their own — 88.6%. (The lowest score was 37.6% and the state average was 63.6%.)

In an email, Lesley Midkiff, marketing director at Westminster Village, said that the facility’s staff is vigilant about sending residents back to the hospital if health issues arise. At the same time, she said, staffers “push the residents just enough to regain independence and recover quickly from their short term stays.” Both priorities have the “residents’ best interest” in mind, she said.

If a facility has an average or low quality score, Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home industry group, recommended that people look closely at various measures and try to figure out where the institution fell short. Call the facility and ask them to explain, he said. Also, review Nursing Home Compare’s information about staffing and health inspections, Gifford suggested, and visit the facility if possible.

Variations within nursing homes. The newly published Nursing Home Compare data also shows that institutions aren’t always equally adept at caring for short-stay and long-stay residents.

Disparities in facilities’ ratings for short- and long-stay patients are common. Of 13,351 nursing homes that received both ratings, 32% received the same star ratings for the quality of care received by short-stay and long-stay residents. Another 32% of facilities received higher star ratings for short-stay residents, while 36% got higher ratings for long-stay residents. About one-third of the time, these rating categories were one star apart, but in another third of cases, they varied by two or more stars — a significant discrepancy. (This analysis does not include 2,212 nursing homes for which data was missing.)

In Phoenix, Desert Terrace Healthcare Center, which bills itself on its website as the city’s “premier location for short-term rehabilitation and long-term care,” is one such facility. Its quality-of-care rating for short-term residents was two stars, while its rating for long-term residents was five stars. Notably, hospital admissions and ER visits for short-stay patients were higher than the state average, while the portion of short-stay residents whose mobility improved was lower than average.

In an email, Jeremy Bowen, the facility’s administrator, wrote that the facility had a good record of managing pain and bedsores and limiting antipsychotic prescriptions for short-stay patients. Factors such as hospital readmissions depend on community resources and patients’ understanding of their health needs, which are difficult to control, he noted.

Sierra Winds, part of a continuing care community in Peoria, Ariz., has a similar split in quality ratings (two stars for short-stay residents, five stars for long-stay residents). On four of six measures used to calculate star ratings for short-stay residents, it performed worse than the state average.

“Sierra Winds remains committed to providing the highest quality care and services to its residents,” wrote Shannon Brown, the facility’s executive director, in an email. “We are proud of our 4-star rating with CMS [the Centers for Medicare & Medicaid Services].”

That’s the facility’s overall rating (this includes data about staffing and health inspections). But it doesn’t address the split in scores for short-stay and long-stay patients, which raises a red flag and should certainly cause seniors and their families to ask follow-up questions.

“If I’m a patient looking for a place for a short-term rehab stay, I really want to know how patients who look like me did,” said Dr. Rachel Werner, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a quality-measurement expert.

KHN senior correspondent Jordan Rau contributed to this report.

Bank Accounts and the Power of Attorney Designation

June 4, 2019

NAELA News:

Michael P. Affuso, EVP/Director of Government Relations, NJBankers

A power of attorney is a useful document for people to appoint someone to handle their financial affairs if, for some reason, they cannot do so themselves. It is one of the three important documents prepared by attorneys for their estate planning clients. This document allows the “agent” or “attorney-in-fact” identified in the document, to sign checks, open and close accounts, sell real estate, sign tax returns and other financial acts, on behalf of the “principal”, the person signing the document.

The agent is a fiduciary under the law. This mean that the agent must act in the best interest of the principal. Money belonging to the principal cannot be spent on the needs of the agent, or for the interests of the agent. If this duty is violated, legal liability may ensue. This raises the issue of how banks should designate an agent on the account of a principal.

Many times an agent will ask to be added to the account of a principal. Often, this is a daughter or son of a parent depositor. The power of attorney document will be presented, or the child will appear at the bank branch with the parent asking to be placed on the parent’s account. It is important that the agent not be added to the account as a joint owner, but as agent under a power of attorney.

Joint Owners Have Full Rights of Ownership

A joint owner of an account has an ownership right to all of the money in the account. If the account merely says, “Jane Smith and Susan Smith”, both can use all of the account proceeds for their own purposes, by law. This is not what the power of attorney intended, nor is it consistent with the legal duties of the agent. In fact, it is not an uncommon complaint that the agent took all of the parent’s money and disappeared, or used the money for their own needs. Financial exploitation by the elderly is common, and, statistically, it is often inflicted by family members.

Law enforcement officials are reluctant to pursue this type of theft because the joint owner has a legal right to take the money out of the account. The legal duties of the agent are irrelevant, because the account was jointly held. This would not be the case if the letters, “POA” appeared after the agent’s name on the account.

Joint Accounts Are Subject To The Liabilities Of The Agent

If an agent is placed as a joint owner on a bank account, such as a daughter on her mother’s account,  the account is subject to the liabilities of the agent/daughter. Any number of things can unexpectedly happen to the daughter and expose the mother’s money to creditors and others. For example, the daughter could be sued, file bankruptcy, get divorced or die. If this happens, the mother’s money in that account will be subject to pay the judgment, be placed under the control of the bankruptcy trustee, be involved in the divorce proceedings, or be part of the daughter’s estate. This could cause serious problems for the true owner of the account.

Properly Designate All Accounts By Using “POA”

If an account holder wants to add someone to their account as power of attorney, it is extremely important that the agent be designated properly. The agent should be designated on the account as “POA”. In this way it is clear that the son or daughter is acting on the account in a fiduciary capacity.

This will empower law enforcement officials to take action in the event of financial abuse and will protect the principal’s money from claims involving the agent. This designation of “POA” is crucial to avoiding the financial abuse of the elderly.  It will also prevent catastrophic loss of money belonging to the principal if creditors or others have claims against the agent.

 

Advocates Urge ABLE Age Increase to Sustain System

June 4, 2019

NAELA News:

By David M. Goldfarb, Esq.

The ABLE Age Adjustment Act would raise the aging of onset of a disability to 46.

Four years ago, Congress passed the Achieving a Better Life Experience (ABLE) Act of 2014, creating tax-favored accounts for persons with disabilities to save and pay for disability-related expenses. Since its passage, 41 states and the District of Columbia have created programs.

Yet despite more than 25,000 ABLE accounts opened, the National Association of State Treasurers (NAST) warned that the current program’s trajectory is not sustainable. To achieve sustainability, 390,000 ABLE accounts would need to be opened by 2021.

NAELA’s history with the legislation is complicated. While we supported the concept, the initial draft, which had no limits to funding an account, included a Medicaid payback provision. That put previously protected third-party money at risk if placed in an ABLE account instead of a third-party special needs trust.

But the final version proved to be a great benefit. That is for those who could qualify. Vastly scaled back from the initial draft, it capped yearly contributions to the gift tax exclusion amount ($15,000 in 2019). While the Medicaid payback remained, the money at risk was now vastly lower. Unfortunately, the scaled back benefit only applied to those who developed a disability before the age of 26.

The final bill’s age limitations upset many in the disability community who had lobbied hard for the ABLE Act for years only to see many individuals unable to qualify.

Given this, disability advocates have since focused on expanding the age limit needed to qualify.

That led to the introduction of the ABLE Age Adjustment Act last Congress. The legislation would raise the aging of onset of a disability to 46. Many have asked why 46? The answer is that it’s halfway to 65 from 26, the original cut-off age.

In March of this year, Sens. Bob Casey (D-PA), Jerry Moran (R-KS), Chris VanHollen (D-MD), and Pat Roberts (R-KS) along with Reps. Tony Cardenas (D-CA), Cathy McMorris Rodgers (R-WA), Steve Cohen (D-TN), Brian Fitzpatrick (R-PA), Michael Turner (R-OH), Max Rose (D-NY), and Debbie Wasserman Schultz (D-FL) reintroduced the legislation.

The timeline and likelihood for passage remain unclear. However, both Republicans and Democrats would like to address a few issues with the big tax reform bill passed in 2017. In addition, a number of tax provisions expire, requiring an extension. That could give rise to an opportunity later in the year for a legislative vehicle to include the ABLE Age Adjustment Act.

The good news from an advocacy perspective is that raising the age solves the main issue for NAST: increasing the number of accounts. According to the National Disability Institute (NDI), about 6 million individuals could qualify under current law. By raising the age to 46, an additional 8 million could qualify.

Earlier this year, as NAELA’s Sr. Public Policy Manager, I was selected to become a co-chair of the Consortium for Citizens with Disabilities Financial Security Task Force, which in part coordinates strategy and outreach for passing the ABLE Age Adjustment Act. By providing the expertise of NAELA members to Congress and the disability community at large, hopefully we’ll be able to make a difference in your clients’ lives by expanding access to these accounts.

About the Author

David M. Goldfarb, Esq., is NAELA’s Senior Public Policy Manager.

Remarriage terminates widow’s eligibility for disabled veterans property tax exemption

June 4, 2019

There are some circumstances in which a person’s eligibility for governmental benefits is affected by his or her marital status. This is certainly the case with Medicaid/MLTSSSupplemental Security Income; and exemption from inheritance tax on receipt of an inheritance. The NJ Appellate Division had the opportunity recently to decide whether a veteran’s widow would retain her eligibility for his veterans’ property tax relief if she remarried. In  Pruent-Stevens v. Toms River Twp., the property owner’s first husband was an honorably-discharged Viet Nam veteran. He died before 1997 at a time that he had a pending claim for service-connected compensation benefits due to exposure to Agent Orange defoliant. She remarried , and her second husband died in 1997.  eventually, in 2014 (!) the Veterans Administration approved the claim and declared that the first husband had died of a service-connected disability. She then filed for disabled veterans property tax relief from Toms River.

The relevant statute allows a town to grant tax relief to the widow/widower of a disabled veteran  provided that s/he “has not remarried.”  The issue in the case was whether that status only pertained to the time that the application for the exemption was filed, or if it was a blanket cut-off for exemption eligibility for a widow who remarries at any time.  The New Jersey Tax Court  decided that the phrase “has not remarried” should be interpreted to mean that as long as the widow/er wasn’t married at the time of the application for exemption, the exemption would be available. In other words, it could turn on and off. She was unmarried in 2016 when her application was filed, so the Tax Court ruled in her favor. The Town appealed.

The Appellate Division reversed.  Finding that she had no “vested right” at the time of her 1997 remarriage, and that in other areas of New Jersey law, “widow” is defined as a person who has not remarried,  the court ruled that the potential entitlement to the exemption was lost as a result of having ever remarried.

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‘Medicare for All’? How About ‘Medicaid for More’?

June 3, 2019

On Monday, Washington Gov. Jay Inslee signed the nation’s first “public option” health insurance bill. Other states aren’t far behind.

BY  MAY 13, 2019 AT 9:19 AM

SPEED READ:

  • Washington Gov. Jay Inslee signed the nation’s first “public option” bill. 
  • Similar legislation is pending in 10 other states.
  • Some states may need the federal government’s permission.

Colorado and Washington state both passed legislation in April that could offer a new health insurance option to people who make too much money to qualify for Medicaid but not enough to afford private health coverage.

Most Medicaid recipients pay no premiums, but the idea of letting some people buy a form of Medicaid is gaining steam.

The public option was first introduced in Nevada in 2017 at a time when Congress seemed poised (yet ultimately failed) to repeal the Affordable Care Act and leave millions of people without health coverage. The state legislature passed a bill that would have let anyone buy publicly run insurance. It was vetoed by then-Gov. Brian Sandoval, but similar proposals have since been introduced in states across the country. In addition to Colorado and Washington, legislation to study or start a public option or Medicaid buy-in program is currently pending in Connecticut, Maine, Massachusetts, Minnesota, Missouri, New Hampshire, New Jersey and Oregon.

No state, however, has pushed the proposal further than Colorado, where the bill has been sent to Gov. Jared Polis, or Washington, where Gov. Jay Inslee — a 2020 candidate for president — signed the bill on Monday. The expansion of public health insurance is a key talking point among Democrats running for president — several of whom have endorsed a “Medicare for All” bill in the U.S. Senate.

“It’s a landmark move, and [states] are a great testing ground to see how much the public option can reduce costs,” says Tara Straw, a senior policy analyst for the liberal Center on Budget and Policy Priorities.

According to a survey by the United States of Care, a significant majority of voters — Democrats and Republicans — support Medicaid buy-in. Advocates believe a public option could offer a lower-cost alternative to the health-care marketplace and spur enough competition to lower premiums overall.Critics, including the insurance industry, argue that introducing a public option would force private insurers off the marketplace, resulting in fewer options for care.

“Introducing the concept of a public cure for what is broken in Obamacare seems hypocritical,” Jim Smallwood, a Colorado state senator and insurance broker, told the Associated Press.

No two of the proposed Medicaid buy-in bills are the same.

Minnesota’s would allow people to sign up for Medicaid if they don’t qualify for tax subsidies on the exchange or live in a county with only one plan.

Washington’s will have the agency that runs Medicaid contract directly with at least one privatehealth insurer to offer a “qualified health coverage” plan that meets Affordable Care Act standards on the state’s marketplace. It will expand subsidies to people making up to 500 percent of the federal poverty line, or $62,450 a year, for a single person.

Colorado’s bill, on the other hand, is lighter on details. It directs the state’s departments of Health Care Policy and Regulatory Agencies to draft a public option that would compete with private insurance plans. It’s unclear whether this public option would be sold on or off the marketplace and whether it would offer subsidies. Some say the subsidies are key.

“If you don’t offer tax credits, I don’t think there’s a super good chance for them to be competitive,” says Emily Johnson, director of health policy analysis at the Colorado Health Institute.

Subsidies aren’t the only element of Medicaid buy-in that states would have to decide. There are many other questions surrounding eligibility, benefits and whether the federal government would greenlight their plans. If states want to offer federal tax subsidies, they may need the federal government’s permission to implement Medicaid buy-in. Washington, however, won’t need its approval since the state would contract with a private insurer. While the head of the Centers for Medicare and Medicaid Services, Seema Verma, reiterates that she wants to give states more health-care flexibility, she has publicly lambasted “Medicare for all.”

Colorado’s proposal is due by November. Some observers commend the state’s “pass first,
figure out the details later” tactic.

“It’s a smart approach to complicated policy,” says Straw. “It’s understandable they want
time to figure out what’s going to work best.”

Both Colorado and Washington have a blue trifecta — Democratic governors and majorities in the House and Senate. It’s a level of power that Democrats have only had in Colorado since November.

“This is the year to do stuff like this,” says Johnson. “Also our bill is the study of the state option, not the actual design of the state option, making it a bit easier to pass.”