This year, many states have continued to pursue federal approval for a range of proposals affecting Medicaid coverage, such as seeking modifications to the Affordable Care Act’s (ACA) Medicaid expansion or adding Medicaid work requirements.
Currently, nine states have implemented expansion through Section 1115 waivers to impose conditions such as monthly premiums, lock-out provisions for non-payment, and work requirements on certain Medicaid enrollees. While some Medicaid waivers approved by the federal government that include work requirements have faced legal challenges, other states — including those that have not implemented Medicaid expansion — are continuing to seek federal approval to condition Medicaid eligibility on work, with nine additional proposals currently pending.
The following is an overview of some of the current state Medicaid coverage waiver activity and other state actions affecting health coverage, including Tennessee’s recent block grant proposal.
State Changes to Medicaid Expansion Passed by Ballot Initiatives
Earlier this year, Idaho’s governor signed into law a number of changes to the Medicaid expansion ballot measure approved by voters in November 2018. One component of the law required the state to seek a 1332 waiver to enroll individuals eligible for expanded Medicaid who had income between 100 to 138 percent of the federal poverty level (FPL) in subsidized exchange coverage, although these individuals could opt for Medicaid coverage instead. However, in late August the Centers for Medicare & Medicaid Services (CMS) rejected the state’s waiver request, citing that it did not meet the deficit neutrality guardrails required of 1332 waivers. State officials have indicated that they will resubmit the application with additional information, although CMS noted in its letter that even a revised application would likely still not demonstrate compliance with those guardrails. Another aspect of Idaho’s law modifying the voter-approved Medicaid expansion directs the state to seek a waiver to implement Medicaid work requirements for most expansion enrollees, and the state recently submitted this 1115 waiver request for federal approval. If the waivers are not approved by Jan. 1, 2020, the state law requires implementation of traditional Medicaid expansion.
Similar to Idaho, voters in Utah passed a measure last November to implement Medicaid expansion, and in February state legislators enacted a law that significantly alters the voter-approved expansion in a number of ways. The law requires the state to seek a series of waivers, outlined in the state’s implementation toolkit, through a potentially four-step process, depending on what CMS approves. In March, CMS approved the state’s first request — the Bridge Plan — to expand Medicaid to only those earning 100 percent of FPL at the state’s regular federal medical assistance percentage (FMAP) rate, include an enrollment cap if projected costs exceed state appropriations, require individuals with access to employer-sponsored insurance (ESI) to enroll in that coverage with Medicaid premium assistance, and add work requirements in 2020. In May, the state submitted the second waiver proposal for the enhanced FMAP that the ACA provides for the expansion population while keeping the expansion eligibility level at 100 percent FPL, but CMS indicated that it would not provide the enhanced FMAP for a partial expansion. This second proposal also maintains the enrollment cap, work requirements, and ESI premium assistance from the initial waiver, adds in 12-month continuous eligibility and lock-out provisions for non-compliance with certain activities, and notably requests to implement a per capita cap model for receiving federal Medicaid funds for the new eligibility group. Although CMS did not approve the enhanced FMAP for the partial Medicaid expansion, the governor issued a statement that the state would move forward with requesting approval of the other proposal components, and the state submitted the waiver request in late July. If CMS does not approve this per capita cap proposal, the state plans to request permission to implement a “fallback” plan — the third step in the state’s implementation plan — that expands Medicaid to the ACA’s 138 percent of FPL eligibility threshold and provides the state with the enhanced expansion FMAP, and includes work requirements, an enrollment cap, and lock-out provisions. The final option – if this third plan is not approved – is implementing traditional Medicaid expansion through a state plan amendment, as was passed by the voters.
Nebraska was the third state in 2018 to pass Medicaid expansion through a ballot initiative, and while state legislators there did not follow the same route as Idaho and Utah, expansion in Nebraska has not yet occurred because the state intends to seek modifications to the expansion. State officials submitted a state plan amendment for expansion this past April, indicating the state would seek a waiver to modify its existing managed care program to include the expansion population and provide different benefit packages based on whether enrollees complete certain wellness requirements. Expansion will occur no later than Oct. 1, 2020, and the plan eventually will also incorporate work requirements for eligible individuals wishing to remain in the “prime” coverage option, which offers more robust benefits such as dental and vision services.
Activity in Medicaid Expansion States
Montana originally implemented Medicaid expansion through a waiver because the state requires certain individuals to pay premiums. The expansion was scheduled to sunset in July of this year, but in April the legislature passed a bill, signed by the governor in May, to continue expansion that added work requirements for most enrollees. The state’s waiver amendment also seeks to maintain the original waiver’s implementation of 12-month continuous eligibility and modify the monthly premium structure to be based on the amount of time an individual is enrolled. The federal comment period for the waiver amendment recently closed.
In Virginia, Democratic Gov. Ralph Northam and Republican state legislators negotiated a compromise to expand Medicaid with work requirements in 2018. Coverage became effective in January of this year, but the work requirements were not implemented as the state needed to seek federal permission through a waiver. The state is now negotiating to receive federal funding for employment supports, as Northam’s administration has indicated that the state cannot afford to implement the work requirements without these federal dollars. Some Republican state legislators are characterizing the request for this federal funding as an effort to backtrack on the compromise struck last year between them and the governor.
While New Mexico originally implemented the ACA’s traditional Medicaid expansion, the state sought and received approval in December 2018 to add premium and copayment requirements and waive retroactive eligibility for certain expansion enrollees. However, under Gov. Lujan Grisham, the state is now requesting to amend the waiver and remove the copayments, premiums, and waiver of retroactive eligibility.
Activity in Non-Medicaid Expansion States
Like last year, voters in some nonexpansion states will have the chance to consider expansion in 2020. Groups in Oklahoma indicated that they have gathered enough signatures to put expansion before voters in 2020. Medicaid expansion proponents in other states — specifically Missouri and South Dakota — are also attempting to place the issue before voters in 2020. Additionally, in Mississippi’s upcoming gubernatorial election in November, voters will decide between a Republican who opposes expansion and a Democratic who supports it.
North Carolina’s Democratic Gov. Roy Cooper vetoed the state budget in June in part because it did not include Medicaid expansion. However, in mid-September state legislators in the House voted to override the governor’s veto. While the Senate still needs to hold a vote on the veto override, a bill to expand Medicaid with work requirements and premiums has been added back to the legislative calendar.
Georgia is currently drafting two waiver proposals as part of a law signed by the governor in March. The state is expected to submit an 1115 waiver proposal to expand Medicaid to only those earning 100 percent of FPL, as well as seek federal approval through a 1332 waiver to implement a reinsurance program.
Beyond continuing efforts to expand Medicaid or modify laws to do so, block grants have surfaced again. Tennessee has developed a draft proposal to shift federal funding for most of the state’s Medicaid program into a version of a block grant, which would be a significant change and is based on a state law passed earlier this year. Under the plan, the state would receive a capped amount of federal Medicaid funding for low-income parents, children, and individuals with disabilities. Unlike a traditional block grant — which the state acknowledges its plan differs from — the state is requesting additional funding if enrollment rises above a certain threshold, but the funding amount would not be reduced if enrollment declined. Additionally, the funding cap does not include state spending on individuals dually eligible for Medicaid and Medicare, disproportionate share hospital (DSH) payments, outpatient prescription drug expenses, or administrative costs, and any savings achieved from the financing model would be divided evenly between the state and the federal government (the state’s current federal match rate is 65 percent). The state is also requesting additional flexibilities, such as modifying the amount, duration, and scope of benefits without federal approval or public comment and implementing a closed formulary for prescription drugs. The waiver request also proposes to exempt the state from federal regulations for managed care plans. Some policy analysts have identified that federal law does not allow Medicaid’s financing model to be restructured through the 1115 waiver authority, and if CMS does approve the waiver it is expected to face legal challenges. Tennessee also submitted a separate waiver request in December 2018 seeking to implement Medicaid work requirements for low-income parents and caretakers, which is still awaiting federal approval.
Legal Challenges to Medicaid Work Requirements
Medicaid waivers containing work requirements approved by CMS have been halted by court rulings earlier this year in Arkansas, Kentucky, and New Hampshire, and a legal challenge was recently filed against Indiana’s approved work requirements. Earlier this month, a three-judge panel heard oral arguments on the federal government’s appeal of the Arkansas and Kentucky rulings, and the judges noted that the administration had not considered the coverage losses resulting from work requirements. The ruling by this federal appeals court will have significant implications for Medicaid work requirements overall, and while they did not provide specific information about timing for the decision, it is expected before the end of the year. The court challenges are already beginning to have some implications — on Oct. 17, 2019, Arizona informed CMS that it would postpone implementation of the state’s approved Medicaid work requirements due to the litigation in other states. Additionally, a recent study conducted by the Government Accountability Office (GAO) recommended that CMS should improve its oversight of the administrative costs associated with work requirement waivers, which GAO found can be significant, ranging from under $10 million to over $250 million.
In addition to the next round of court decisions on Medicaid work requirements, states are waiting to see if federal guidance on Medicaid block granting will be issued soon — which is currently under review at the Office of Management and Budget. Similar to how states are seeking to implement Medicaid work requirements despite legal challenges, if CMS provides guidance and approves Tennessee’s block grant proposal, other states may also pursue this financing model, even if the block grant is challenged in court. Also, whether CMS and states that have been hesitant to expand will be able to find a middle ground on Medicaid expansion remains a question, and how decisions play out in Idaho and Utah in particular, will be significant for future actions. Similar to this past year, in 2020 states are expected to continue to seek new ways to test the boundaries of Medicaid coverage waivers and manage their Medicaid programs.
NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.
Substance use disorders (SUD) and mental health conditions are prevalent among pregnant and parenting women in the United States, and they have far-reaching consequences for the health and well-being of women and their children. Integrated care models that support pregnant and parenting women’s physical and behavioral health and social service needs can improve outcomes for women and children and reduce health care costs.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the federal Maternal and Child Health Bureau of the Health Resources and Services Administration (MCHB, HRSA), the National Academy for State Health Policy (NASHP) is working with states to support and advance innovative policy initiatives that improve access to quality health care for pregnant and parenting women.
As part of the MCH PIP initiative, NASHP is convening a two-year policy academy including eight state teams made up of representatives from state Medicaid agencies, public health agencies, mental health/substance use agencies, and other state stakeholders. States selected to participate in the first cohort of the NASHP policy academy include:
- New Jersey
- South Carolina
Over the next two years, these states will identify, promote, and advance innovative, state-level policy initiatives to improve access to care for Medicaid-eligible pregnant and parenting women with or at risk of SUD and/or mental health conditions. NASHP will work with the states to identify high-priority policy issues, challenges, and opportunities through targeted technical assistance, peer-to-peer learning, analyses of policy issues, and development of policy briefs and other resources that will be disseminated nationally.
While many states have identified pregnant and parenting women as a priority population for their SUD and behavioral health efforts, challenges and opportunities persist. NASHP recently published two Issue Hubs that provide valuable resources, including information on the Centers for Medicare & Medicaid Services’ Maternal Opioid Misuse (MOM) Model. They are available at:
- Resources to Help States Improve Integrated Care for Pregnant and Parenting Women: This Issue Hub provides valuable resources for states interested in using the Maternal Opioid Misuse (MOM) model and others to improve access to comprehensive and coordinated care and implement innovative payment and care delivery models for pregnant and parenting women eligible for Medicaid.
- Resources to Help States Improve Integrated Care for Children: This Issue Hub provides valuable resources for states interested in the Integrated Care for Kids (InCK) Model and others working to implement payment, coverage, and cross-agency strategies to improve for integrated care coordination of behavioral, physical and health-related social needs for children eligible for Medicaid or the Children’s Health Insurance Program (CHIP).
The opioid epidemic is having a devastating impact on children and families and placing a significant strain on states as they work to develop effective programs and find new funding to respond to this crisis.
To address the crisis and promote healthy child development, states are implementing innovative whole-family approaches to prevention and treatment (see below). On the federal level, new funding is available and recently the federal Center for Medicare and Medicaid Innovation announced its Integrated Care for Kids model, which states can use to improve care and outcomes while reducing costs through early identification, integrated care coordination, and case management for physical and behavioral health care and non-clinical local services.
Children can experience many negative consequences as a result of their parents’ opioid use disorder (OUD). Prenatal opioid exposure can cause neonatal abstinence syndrome in infants, which is usually treated by costly hospitalizations and may increase the risk of developmental disabilities. Children affected by parental substance misuse are at increased risk of adverse childhood experiences and trauma, which can have significant short- and long-term physical, mental, and behavioral consequences.
A new National Academy for State Health Policy (NASHP) issue brief, written in partnership with the Alliance for Early Success, identifies the following promising state strategies developed by Kentucky, New Hampshire, and Virginia to support children and families:
- Facilitate access to and coverage of services by improving identification of at-risk infants and children, enabling rapid access to treatment, expanding coverage of services, and enhancing provider capacity. For example, New Hampshire’s Project First Step embeds licensed alcohol and drug counselors (LADCs) within its Division of Children, Youth, and Families (DCYF) district offices. The LADCs train child welfare and juvenile justice staff about substance misuse — including screening and facilitating access to treatment — to enable DCYF staff to better meet the needs of children and families affected by OUD.
- Implement family-focused care delivery models, such as providing family-centered treatment approaches for the family unit, offering care at home and in the community, coordinating care, and providing trauma-informed care. Virginia’s Medallion 4.0 Medicaid managed care program contract requires Medicaid managed care organizations to provide specialized care coordinators for substance-exposed newborns and align a mother’s and infant’s care plan. Additionally, Virginia’s Medicaid 4.0 contracts promote delivery of trauma-informed care, particularly for children impacted by the foster care system.
- Align and maximize resources across systems by sharing data and leveraging diverse funding sources. Kentucky’s Sobriety Treatment and Recovery Team (START) program is a family-centered, service delivery model within the state’s child welfare system that pairs families affected by substance use disorder (SUD) with a child protective services (CPS) worker and a family mentor who has lived experience with SUD. The CPS workers and family mentors coordinate care, offer rapid access to treatment, and provide comprehensive wrap-around services. The program weaves together funding from a Title IV-E waiver demonstration, Medicaid, the Temporary Assistance for Needy Families block grant, and state general funds. The state has also established a data-sharing agreement to advance the program between its Department for Community Based Services and its Department for Behavioral Health, Developmental, and Intellectual Disabilities.
An additional report and webinar exploring state strategies to support pregnant and parenting women affected by substance use disorders, including opioid use disorder, will be published in the weeks ahead.
The opioid epidemic continues to have devastating consequences for children and families across the country, with growing social and financial implications for states. The National Academy for State Health Policy (NASHP), in partnership with the Alliance for Early Success, interviewed Kentucky, New Hampshire, and Virginia officials representing state Medicaid, child welfare, and behavioral health programs to explore how their child-serving agencies were responding to the opioid epidemic. This new report explores:
- State strategies to support young children and families affected by the epidemic;
- Available state and federal funding sources for these initiatives; and
- Key considerations for states working to improve services and outcomes for this vulnerable population.
- Listen to a webinar that featured two New Hampshire officials detailing their state’s strategies to support families affected by the opioid epidemic. The speakers are:
- Geraldo Pilarski, Bureau of Community, Family, and Program Support Administrator, New Hampshire Division for Children, Youth and Families, and
- Erica Ungarelli, Bureau for Children’s Behavioral Health Director, New Hampshire Division for Behavioral Health
Download webinar slides. View the webinar:
- Explore resources from #NASHPCONF18’s session: Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
Last week, for the first time the Centers for Medicare & Medicaid Services (CMS) approved a Medicaid waiver application that includes work and community engagement requirements as a condition of Medicaid eligibility for certain enrollees. Approval of Kentucky HEALTH’s Medicaid waiver proposal, which will run through Sept. 30, 2023, came one day after CMS released guidance allowing states to implement these types of requirements.
The following outlines key components in the state Medicaid program’s work and community engagement requirements and other aspects in the approved Medicaid demonstration project:
Work and Community Engagement Requirements:
- Applicable population groups: Able-bodied adults aged 19-64
- Exempt population groups: Former foster care youth; pregnant women; primary caregivers of a dependent (either minor child or disabled adult; limited to only one exemption per household); medically frail individuals; individuals diagnosed with acute medical conditions that would prevent them from compliance with requirements (validated by a medical professional); full time students
- Amount of hours required: 80 hours/month to maintain eligibility
- Qualifying activities: Subsidized or unsubsidized employment; self-employment; job skills training; job search activities; enrollment in educational program related to employment (e.g. management training); general education (e.g. high school, GED, college or graduate education, English as a second language); vocational education and training; community work experience; community service/public service; caregiving services for a non-dependent relative or other individual with chronic, disabling health conditions, or participation in substance use disorder treatment
- Enrollees meeting these requirements: Some enrollees will be deemed as satisfying requirements by the following:
- Individual meets requirements of the Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF) employment initiatives or is exempt from having to meet those requirements
- Individual is enrolled state’s Medicaid employer premium assistance program (a spouse or dependent of beneficiary enrolled in premium assistance program is also exempt)
- Individual is employed at least 120 hours per month
- Reporting frequency:
- Enrollees must document participation in any one or combination of qualifying activities on at least a monthly basis.
- Individuals deemed as satisfying the requirements will not be required to actively document participation in qualifying activities, although they will need to timely report changes in eligibility.
- Penalties for noncompliance:
- After a one-month opportunity to come back into compliance, individuals who fail to meet requirements for a month will have their benefits suspended unless a good-cause exemption is met.
- Individuals can reactivate eligibility on the first day of the month after the individual complies with the requirements in a 30-day period or completes a state-approved health literacy or financial literacy course.
- Individuals who, during a suspension period, become pregnant, are determined to be medically frail, become a primary caregiver of a dependent (either minor child or disabled adult — limited to only one exemption per household), are diagnosed with an acute medical condition that would prevent them from compliance with requirements (validated by a medical professional), or become a full-time student, or become eligible for Medicaid under an eligibility group not subject to the work and community engagement requirements can reactivate benefits, with an effective date aligned with their new eligibility category or status.
- Individuals with suspended benefits at the time of their re-determination date who do not qualify for an exemption will have their enrollment terminated and will have to submit a new application to regain coverage.
- Implementation details:
- Requirements will be implemented on a regional basis. The state will assess areas that experience high rates of unemployment, limited economies and/or educational opportunities, and those with a lack of public transportation to determine whether there should be further exemptions from the work and community engagement requirements and/or additional mitigation strategies.
- Kentucky HEALTH beneficiaries who have not been subject to the requirements in the past five years will be provided a three-month period prior to being subject to the requirements.
Other Notable Waiver Components Include:
- Disenrollment and a six-month non-eligibility period for individuals who do not provide necessary documentation/information to complete annual eligibility redetermination or report a change in circumstance that would affect eligibility, with some exceptions;
- Use of My Rewards Accounts, which allows enrollees to earn incentives to use for enhanced benefits;
- Premiums charged as a condition of eligibility for enrollees earning more than 100 percent of the federal poverty level (FPL), with disenrollment and six-month non-eligibility period for nonpayment (exceptions include pregnant women, former foster care youth, and medically frail individuals). Individuals earning below 100 percent of FPL are also subject to premiums, but not as a condition of eligibility (nonpayment results in requirement to pay copayments for services and lack of access to My Rewards Account for six months);
- Access to certain substance use disorder treatment services through an opioid/substance abuse program;
- Waiver of non-emergency medical treatment for certain populations and services; and
- Waiver of retroactive eligibility for certain populations.
Note: Kentucky initially implemented the Affordable Care Act’s (ACA) traditional Medicaid expansion under Democratic Gov. Steve Beshear. In 2016, newly-elected Republican Gov. Matt Bevin sought a waiver to modify the state’s Medicaid expansion model.
Home visiting programs have a long track record of improving health and life outcomes of children and families, such as increasing school readiness and reducing hospitalizations, while generating long-term savings. States use home visiting to target interventions for some of their most vulnerable populations and utilize multiple private and public funding streams, including Medicaid, to support these programs. This issue brief, developed with support from the Alliance for Early Success, highlights Medicaid and other funding sources available to support these services and explores opportunities to integrate home visiting into state health reform efforts. The brief also features examples of how states use Medicaid to finance home visiting programs.
Learn more about Community Health Workers: Policy Opportunities for Population Health and Patient-Centered Health Care at NASHP’s 30th Annual State Health Policy Conference Oct. 23-25, 2017, in Portland, OR.
Discover how states are designing, implementing, and funding their community health worker programs across the nation at NASHP’s community health worker interactive map.
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.