State-Specific Medicaid Program Changes

The following information is paired with our blog, Emerging Themes in Proposed State Medicaid Waivers.

Key Pending Waiver Requests for ACA Medicaid Expansion Eligibility Groups

  • Seeking to add work requirements as a condition of eligibility:
    • Arizona (20 hours/week for school/job training; unspecified for employment or job search)
    • Arkansas (80 hours/month)
    • Indiana (Average of 20 hours/week)
    • Kentucky (5 hours/week increasing to 20 hours/week after first year of enrollment)
  • Requesting to cap eligibility for expansion population to 100% FPL: Arkansas

Arizona originally implemented the ACA’s Medicaid expansion without a waiver (and prior to the ACA the state had expanded coverage to childless adults up to 100% FPL). In 2015 under the administration of Governor Ducey, the state developed a plan requiring expansion enrollees to contribute premium payments to health savings accounts, pay copayments of up to three percent of income, as well as adding work requirements and limits on lifetime enrollment in the program for most able-bodied adults to five years. Arizona’s waiver was approved in September 2016, although the work requirements and time limits on enrollment were denied. Due to a 2015 state law, Arizona’s Medicaid agency is required to annually request from CMS the ability to implement certain eligibility requirements for able-bodied adults. This includes the previously rejected work requirements and time limits, as well as prohibitions on enrollment for one year for individuals who do not report income changes or inaccurately indicate compliance with the work requirements. The draft waiver indicates individuals can meet the work requirements by being employed, verifying that they are actively seeking work, or attending school and/or a job training program at least 20 hours/week. Public comments on the current draft waiver were accepted through March 2017, and it is anticipated the state will submit the proposal to CMS soon.

Arkansas’ current Medicaid expansion waiver, called Arkansas Works, is an extension of, and modification to, the state’s original 2014 Medicaid expansion waiver that most notably uses Medicaid funds to enroll the state’s Medicaid expansion population into ACA marketplace/qualified health plan (QHP) coverage. Arkansas Works was approved in December 2016 and is effective through 12/31/21, and includes a premium assistance program for employer-sponsored insurance (ESI), premiums for individuals above 100% FPL, incentives for timely premium payments and healthy behavior activities, a conditional waiver of retroactive coverage, and work referrals. Although Arkansas Works had been approved just months before, in March 2017 Governor Hutchinson outlined potential amendments to Arkansas Works. Most notably the proposed changes included adding a work requirement for most non-disabled adults as a condition of eligibility and capping eligibility to 100% FPL. (An estimated 20 percent of individuals in Arkansas Works have incomes between 100-138% FPL; under the proposal these individuals would be eligible for subsidized marketplace coverage.) Because these proposed changes required state legislative action, a special legislative session was convened and legislators passed a bill that the governor signed into law in May. The state has posted the draft waiver for public comment through mid-June. Individuals who are subject to the employment requirements must work or be engaged in certain educational, job training or job search activities for at least 80 hours per month to maintain coverage. If they do not meet these requirements for any three months during a plan year, individuals will be disenrolled and not allowed to reenroll until the next plan year. Through the waiver the state also proposes to eliminate retroactive coverage as well as its ESI premium assistance program and enroll participating and eligible individuals into QHP coverage.

A key feature of the Healthy Indiana Plan 2.0 (HIP 2.0) Medicaid expansion waiver, initially approved in 2015, is enrollee premium contributions to Personal Wellness and Responsibility (POWER) accounts along with a high-deductible plan. Contributions to POWER accounts are required as a condition of eligibility for individuals above 100% FPL, and these individuals can be disenrolled from coverage for six months for unpaid premiums unless they meet certain exceptions. CMS denied Indiana’s request to include a work referral as a condition of eligibility. However, separate from the expansion waiver, the state refers adults covered by Medicaid who are unemployed or working less than 20 hours a week to a voluntary work search and job training program. In January 2017 the state submitted a waiver extension application to continue the HIP 2.0 plan until January 2021, which included requirements for managed care entities to create incentive programs designed to promote employment. The state took further steps related to employment conditions in May by adding an amendment to the application to include work requirements as a condition of eligibility for most non-disabled enrollees. Specifically, individuals will be required to work on average 20 hours per week over eight months during the eligibility period. Individuals can also meet the requirement by participating in the state’s job search and training program or by being enrolled in part-time or full-time education.

Under the administration of former Governor Beshear, Kentucky implemented the ACA’s Medicaid expansion without a waiver. However, after Governor Bevin took office the state submitted a Section 1115 wavier to CMS in August 2016 to modify the state’s Medicaid expansion model, incorporating many of the features of Indiana’s waiver. As of mid-June 2017 the waiver is still pending CMS approval, but it is anticipated that CMS will respond this month.

Through the waiver, the state proposes to create both high deductible accounts for most enrollees and incentive (My Rewards) accounts for all enrollees. The state would contribute $1,000 to the deductible accounts, with funds to be used for non-preventive health care services. Up to 50 percent of any remaining funds from the deductible account can be transferred at the end of the benefit period to the My Rewards accounts. Enrollees can also earn funds for the My Rewards accounts by completing certain health-focused or community engagement activities. Funds in these accounts can be used to purchase benefits not covered (such as dental, vision, over-the-counter medications and gym memberships) and would be deducted for non-emergency use of the ER. The waiver proposal also includes premiums for most non-disabled adults based on income in lieu of copayments, although individuals below 100% FPL can opt to pay Medicaid copayments instead of premiums. For individuals above 100% FPL, premium payments would be a condition of eligibility, and coverage would not begin until after premium payment. These individuals could be disenrolled for nonpayment after a grace period and not permitted to re-enroll for six months or until premiums paid in full and the enrollee completes a financial or health literacy course. Additionally, individuals above 100% FPL would have increasing premiums during their third year of enrollment to greater than 2 percent of income (which would result in higher premiums than those on the marketplace at this income level). The proposal also includes a work requirement as a condition of eligibility for most enrollees (activities besides employment can include volunteer work, job search activities, training and education), which increases from 5 hours a week to 20 hours a week based on time enrolled. The proposal also requests to waive non-emergency medical transportation (NEMT) for the expansion population and eliminate retroactive coverage for most adults. Individuals with access to cost-effective ESI would be required to participate in ESI after the first year with Medicaid premium assistance. Most of the waiver provisions would apply to the adult expansion group, as well as to other non-disabled adult Medicaid enrollees.

In May 2017, the state proposed an amendment to the state’s MassHealth Section 1115 waiver, which is a waiver that affects all of the state’s Medicaid population. Massachusetts has implemented the ACA’s Medicaid expansion without a waiver, and while the state’s current waiver renewal is focused on restructuring the program’s delivery and payment system, the amendment proposes to add benefit changes for the adult expansion group to more closely mirror elements of private market coverage. In March the state sent a letter to CMS that in part requests flexibility in benefit design for the expansion population. Specifically, the state seeks to eliminate non-emergency medical transportation (NEMT) for individuals covered through the MassHealth CarePlus program that covers childless, non-pregnant and non-disabled adults ages 21-64. There would be an exception to provide NEMT to individuals participating in substance use disorder services. The state is also seeking to eliminate its current provisional eligibility rules, which allows an individual to be enrolled in MassHealth for a 90-day provisional eligibility period if eligibility cannot be verified. The state is requesting to discontinue provisional eligibility for individuals ages 21-64 with unverified income, with the exception of pregnant women, adults with incomes up to 200% FPL who are HIV-positive, and individuals with breast or cervical cancer with incomes up to 250% FPL.

Key Pending Waiver Requests for Non-Medicaid Expansion Eligibility Groups

  • Seeking to add premiums:
    • Maine ($14-$66/month)
    • Wisconsin (Depending on income, none or $8/month)
  • Seeking to add work requirements as a condition of eligibility:
    • Maine (20 hours/week, averaged monthly)
    • Wisconsin (80 hours/month)
  • Seeking to add time limits on coverage:
    • Maine (No more than 3 months in 36 month time period unless work requirements are met)
    • Wisconsin (48 month time limit that can be extended if work requirements met; disallow reenrollment for 6 months)
  • Seeking to add drug screening and testing: Wisconsin

In April 2017, Maine issued a draft waiver application to add certain eligibility and coverage requirements for its traditional adult Medicaid population (low-income parents, former foster care youth, individuals receiving Transitional Medical Assistance, and other individuals such as people with breast or cervical cancer or HIV or those receiving partial Medicaid benefits). Maine has not implemented the ACA’s Medicaid expansion, and some of the proposed concepts have not been approved for any Medicaid groups previously. First, the state proposes sliding scale premiums on most adults at all income levels, ranging from $14-$66/month. There would be a 90-day coverage lockout for individuals with incomes at or below 100% FPL who do not pay premiums after a grace period. The state is also proposing work requirements as a condition of eligibility for most enrollees, which could be met through employment or participation in approved job training for at least 20 hours/week (averaged monthly), being enrolled as a student at least half time, or completing a combination of employment and education. Individuals could also comply with the work requirement by participating in volunteer community service 24 hours a month, receiving unemployment benefits, or pursuing career planning/training in caregiver services and also providing these services for a non-dependent individual with a disability. Also, unless individuals meet the work requirements, coverage would be limited to no more than 3 months in 36 month time period. The state is also seeking to waive retroactive eligibility and apply a $5,000 asset test to coverage groups not currently subject to one.

While Wisconsin did not implement the ACA’s Medicaid expansion, the state does have an approved Section 1115 waiver from CMS that provides Medicaid coverage to all childless adults ages 19-64 with incomes up to 100% FPL (the state does not receive the ACA’s enhanced Medicaid match rate for this group). In April 2017, Wisconsin proposed an amendment to add in certain requirements for the population covered by the state’s existing waiver, and the final proposal was submitted in early June. The state modified the original proposal, which required premiums from individuals with income beginning at 21% FPL, and instead proposes that individuals with incomes between 51-100% FPL would have $8/month premiums and those at 50% FPL and below would not face premium requirements. The proposal includes a six-month lockout period for any enrollee who does not pay the premium amount, but third parties—such as hospitals, non-profit organizations, and employers—can pay premiums on behalf of enrollees. Individuals would be able to halve their required premium contributions by undergoing a health risk assessment and meeting certain requirements to address any identified health risks. The revised waiver amendment also imposes cost sharing of $8 for all emergency department visits, both emergency and non-emergency visits (the original proposal charged enrollees $25 for each visit after the first one).

Similar to Maine, Wisconsin is requesting the ability to implement measures that have never been approved by CMS, even for the Medicaid expansion population. Specifically, the state proposes to limit enrollment for most individuals ages 19 to 49 to a total of 48 months, after which they would be disenrolled and not allowed to reenroll for six months (unless they qualify for Medicaid under another eligibility category). However, certain individuals would be exempt and this time limit on enrollment could be modified if an individual meets certain work requirements. Specifically, each month that an enrollee works or participates in job training for at least 80 hours a month would not be applied to the 48-month enrollment limitation. The state is also seeking to have all Medicaid applicants and current enrollees participate in a yearly drug use screening. If these results indicate potential substance use the individual would be required to take a drug test (although individuals who indicate interest in seeking substance use disorder treatment during the screening can forgo the drug test and enter treatment). Individuals with positive drug test results for non-prescribed substances would need to participate in substance use disorder treatment. Individuals who do not meet these requirements would be ineligible for benefits until they comply. Additionally, the amendment requests the ability to use Medicaid funding for up to 90 days of residential substance use disorder treatment in institutions for mental disease. Finally, the state did not request for the current Medicaid match rate to increase for the population covered under the waiver to the ACA’s enhanced match rate for the expansion population.