For more information, please click the program titles and read NASHP’s State Medicaid Quality Measurement Activities for Women’s Health.
Acknowledgement: Thank you to the officials in Washington, DC, Montana, and Minnesota for reviewing their respective highlighted strategies. This infographic is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
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.
Montana recently expanded its Patient-Centered Medical Home (PCMH) program benefits to most children enrolled in Medicaid and the state’s Children’s Health Insurance Program (CHIP). Montana enhanced its PCMH program by:
- Expanding the pool of approved providers;
- Increasing the number of quality measures that must be tracked; and
- Adding complex care management (CCM) – a coordinated care approach designed to help patients and caregivers better manage medical conditions and co-occurring psychosocial factors and reduce hospitalization.
The primary goal of broadening these benefits is to promote the health of children through better preventive care and to appropriately treat chronic diseases by increasing primary care visits and encouraging healthy habits. Over time, the state hopes that this strategy could reduce emergency room visits and drive down costs associated with care.
Montana broadened the eligible providers and services offered to Medicaid and CHIP recipients by integrating the PCMH program with the state’s existing Comprehensive Primary Care Plus (CPC+) initiative that began in 2017. To integrate these programs, Montana aligned its quality measurement and data collection work, so that both initiatives gather and report on the same measures. The state requires that PCMH providers:
- Obtain National Committee for Quality Assurance accreditation;
- Apply to become a PCMH provider; and
- Report on 21 quality metrics. These metrics include management of A1C control in diabetic patients, blood pressure control in hypertension patients, behavioral health screenings and referral to necessary treatment, preventive screenings, and age-appropriate immunizations.
The ultimate goal of PCMHs is to deliver high-quality, cost-effective care by engaging enrollees as stakeholders in their health. The state also recently began building an infrastructure to help ensure the PCMH program is sustainable – these efforts include developing new information technology systems to standardize data collection.
Montana’s work to develop its PCMH model first began in 2009 after the state received a technical assistance grant from the National Academy for State Health Policy (NASHP) to advance the multi-payer Patient-Centered Medical Home Initiative that included Medicaid and CHIP children. Two years later, the state’s PCMH working group was reorganized and is now an official state advisory council comprised of insurance companies, medical providers, public agencies, and consumer advocates.
In 2013, the initiative was enacted with provisions defining expectations and requirements for these medical homes, and a PCMH pilot program was implemented in 2014 that included four federally qualified health centers (FQHCs) and a hospital. That same year, PCMH benefits became available to Medicaid-enrolled children, and in 2017 coverage was expanded to CHIP enrollees. Montana uses a third-party administrator to oversee CHIP members. The third-party administrator uses both the PCMH and CPC+ model, however, they are not the same as the state-run program and do not include the CCM program.
The CCM model engages a comprehensive team of health care professionals. In Montana, the team includes a primary care physician, a licensed nurse, a behavioral health professional, and a social worker in order to treat patients multi-dimensionally. Teams may manage up to 30 members in the CCM program and members must be attributed to the practice through the PCMH model. To be eligible, enrollees:
- Must have two or more chronic conditions;
- Be open to intense, in-home care coordination; and
- Have visited the emergency room multiple times in the last 60 days or had more than one inpatient hospital stay in the last six months.
To access PCMH care, a child’s medical provider must participate in the program.
The non-physician members of the CCM teams try to meet with the member in his/her home and then collaborate with the PCP to design relevant interventions and preventative services based on the teams’ observations. Meeting with the member in his/her home may not happen initially, but it is important to understand the patient’s physical environment to create a holistic treatment plan. These visits must happen at least weekly for the first three months and then at least monthly for the next three months. Visits occur based on the needs of the patient and usually happen more often than required by the program.
The program seeks to engage the member and his/her family in order to meet all of the needs of the household and connect members to appropriate resources. The teams assess other factors affecting the patient’s well-being, such as social determinants of health at the initiation of and conclusion of PCMH appointments to measure the effectiveness of the intervention.
The state’s next steps are to create performance-based incentives for physicians to promote the quality of care, and to continue to refine the PCMH model to address the unique needs of children in Montana.
State spending on health care for employees, retirees and health plans for teachers, university and municipal employees continues to challenge state budgets and raises questions about how best to allocate resources. It is also known that prices in the United States exceed those in other developed nations and that there is significant variation in prices paid by payers. In this webinar, we will hear from state health policy officials who are working to standardize prices paid to hospitals to maintain access and keep spending in check. This webinar will provide descriptions of two state models, and provide an opportunity to discuss the challenges these initiatives face and how they may be overcome. Panelists will answer your questions during this lively and substantive exchange.
Facilitated by Trish Riley, NASHP Executive Director
Marilyn Bartlett, Special Projects Coordinator, Office of the Montana State Auditor, will provide an overview of Montana’s success in implementing reference-based pricing, the savings it has achieved, and discuss whether other purchasers might join the effort.
Dee Jones, Executive Director, State Health Plan, State of North Carolina, will describe developing plans in North Carolina to implement reference-based pricing and the move to direct contracting.
Supported by Kaiser Permanente
State legislatures across the country continue efforts to address the opaque business practices of pharmacy benefit managers (PBMs) to protect consumers and lower prescription drug prices. Montana is taking a new approach by leveraging its insurance department’s regulatory authority over insurance carriers by proposing a bill that tasks insurers with responsibility for overseeing that PBMs distribute prescription drug rebates so that health care costs for consumers will decrease.
In 2018, 20 states enacted 33 laws to regulate PBM licensing processes, prohibit gag clauses, and limit cost-sharing for patients and the federal government followed states’ lead, and enacted a national prohibition on PBM gag clauses. Even though most state legislative 2019 sessions have just begun, lawmakers in over 25 states have already introduced more than 70 PBM regulation bills.
To date, most state legislation directly regulate PBMs, including the National Academy for State Health (NASHP) model PBM legislation, which does not specify which state agency should oversee PBMs, but does establish a fiduciary duty for PBMs to insurers. In an alternative approach, Montana’s proposal specifies its Insurance Department as the lead agency to leverage its regulatory authority over insurers to oversee PBMs and ensure rebates shared within the prescription drug supply chain result in consumer savings. The bill prohibits the practice of spread pricing, which occurs when a PBM reimburses a pharmacy for less than they charged the health plan for a drug and retains the difference. Under Montana’s bill, insurers would receive all of the rebates that PBMs receive from drug manufacturers, and insurers would be required to use those savings to lower out-of-pocket costs for their enrollees.
The measure also prohibits insurers from retroactively denying or reducing a claim payment to a pharmacy, unless the claim was submitted fraudulently. The bill also requires Insurers to review and update the maximum allowable cost list (a payer-generated list of products that includes the upper limit or maximum amount that a plan will pay for generic drugs and brand-name drugs that have generic equivalents available) once every 10 days and provide the list to the insurance commissioner and each provider in the pharmacy network. This chart offers a side-by-side provision comparison between Montana’s bill and NASHP’s model legislation.
Montana’s Commissioner of Securities and Insurance believes this approach will withstand any potential challenges from the pharmaceutical industry and serve as a model for other states. “Senate Bill 71 is a uniquely Montana approach that we’re encouraging other states to adopt as well,” said Kris Hansen, the insurance commissioner’s chief legal counsel.
Using Montana’s proposed bill, NASHP has developed a second PBM model act that other states can adapt if they want to take Montana’s approach and leverage the state’s insurance department’s oversight authority. Explore NASHP’s Center for State Rx Drug Pricing for other model legislation that can help states address drug prices, including drug affordability review (rate setting), manufacturer drug price transparency, and wholesale drug importation.
With 80 bills introduced in 2017, there is a high level of interest in pharmaceutical pricing among state legislators. However, despite legislative sessions wrapping up, very few laws have been enacted. To date, bills have passed in Maryland, Montana, New Mexico, New York, and Utah.
In 2016, Vermont led the way with a price transparency law that, in brief, requires the state to identify up to 15 drugs that account for significant state spending and which have seen price increases of either 50 percent over five years or 15 percent over one year. Manufacturers of those products have to submit price increase justifications to the Attorney General and that information will be made public.
2017 legislation built on Vermont’s first initiative and went a bit further to address drug pricing.
Legislation in Utah directs the Department of Health to study the feasibility of a prescription drug importation program that could be certified by the Secretary of the U.S. Department of Health and Human Services. The Utah Department is to report back to the Legislature by November 2017. Similarly, in Montana a bill directs the State Legislative Council to establish an interagency committee to study drug pricing and state drug spending trends, and make recommendations about drug spending by September 2018.
In New Mexico, the bill would have created an interagency group of state agencies to explore ways of reducing the cost of prescription drugs on state programs. The bill provided direction for what the group should explore but did not require the individual agencies to adopt any of the recommendations. It died on the Governor’s desk.
Maryland’s bill, which is awaiting the Governor’s signature, will give the State Attorney General and Circuit Courts authority to penalize the makers of essential generic and essential off-patent medications for excessive price increases.
This bill permits the Medicaid agency to notify the attorney general when an essential generic medication or off-patent brand drug has an excessive price increase. There are several criteria for what may constitute an excessive price increase among drugs where total cost of 30-day supply is greater than $80 or where the drug price increased more than 50 percent in a year. For these drugs, the attorney general can request manufacturer and wholesaler documentation of product cost increases, or costs associated with increased access and health benefits. If the increase is found to be unjustified, the Circuit Court may impose civil penalties of $10,000 for each violation, roll back the increase, refund to all public and private payers and consumers the excess price and extend to pre-increase drug price for all state health programs for up to one year.
The New York legislation, which passed as part of the state budget and was approved by the Governor, imposes a Medicaid prescription drug spending growth cap. When it appears the Medicaid spending cap will be breached, the Commissioner of Health may select a drug for referral to the state Drug Utilization Review Board (DURB). The DURB is given new authority to assess product value and recommend back to the Commissioner a target Medicaid supplemental rebate amount which would be in addition to the federal Medicaid minimum rebate amount.
If the Commissioner cannot negotiate a rebate for Medicaid that is at least 75 percent of the recommended target amount, the Commissioner is authorized to place the drug on Medicaid prior authorization requiring prescriber justification. It appears that these Medicaid supplemental rebates can be in addition to existing Medicaid supplemental rebate agreements. The law is not specific about how the Commissioner would select a Medicaid drug for referral to the DURB. And the Commissioner could negotiate a Medicaid supplemental rebate with the manufacturer after the manufacturer has received notice of the pending referral to the DURB. The provision is estimated to save $55 million in SFY 2017-2018 and $85 million in SFY 2018-2019.
These legislative milestones are exciting developments in states’ quest to constrain spending on prescription drugs that result from high prices. States are acting in the absence of federal action and attempting a variety of approaches. Since legislatures are still in session in a number of states where drug pricing is a topic of debate, there may be more legislation passed and enacted as these sessions wrap up. For instance, California SB 17 is moving through the State Senate. It is a price transparency bill that goes further than many other proposals and is generating a lot of interest.
NASHP is tracking legislative and executive branch state activity on prescription drug pricing and spending. And we can provide states with expert technical and policy resources to facilitate drug price policy work. Key to the effort is the NASHP state official’s Work Group on Pharmacy Costs, which is building on its 2016 work by developing model legislation and model program design for any state interested in pursuing any of a variety of concrete actions to stem rising drug prices.
Interested state officials should contact Jane Horvath for more information at firstname.lastname@example.org or 202-238-3337.
As 2015 comes to a close, Medicaid expansion activity in states has not slowed down. Currently, 30 states and the District of Columbia have expanded Medicaid, and six of these states have chosen to pursue waivers to implement alternative versions of expansion. As the new year approaches, a number of additional states are considering options for expanding Medicaid—either as outlined by the ACA or through waivers—and other states are planning to propose modifications to their existing expansion models. The following selected state snapshots provide a summary of key highlights from 2015 Medicaid expansion activity and what to watch for in the coming year.
States to Watch in 2016
Alabama: In early 2015, Governor Bentley indicated that his office might consider an “Alabama-specific” version of Medicaid expansion, and his administration is in the process of examining options and continuing communication with federal officials. A governor-appointed task force recommended that state policymakers should find a way to provide health coverage to uninsured individuals, and the task force’s statement outlined the benefits of closing the state’s coverage gap. Whether there will be support from the state legislature is a question.
Kentucky: While former Governor Beshear implemented the Medicaid expansion as defined by the ACA, newly sworn in Governor Bevin has signaled interest in making changes. During his campaign Governor Bevin indicated that he would end the state’s Medicaid expansion if elected, yet more recently Bevin suggested that Kentucky may pursue a waiver to modify the current traditional expansion into a model similar to Indiana’s. A recent Kaiser Family Foundation poll found that approximately seven in 10 Kentucky residents would prefer to maintain Medicaid expansion as is rather than implement changes that would cover fewer individuals.
Louisiana: While Governor Jindal has remained staunchly against Medicaid expansion, incoming Governor-elect John Bel Edwards has expressed strong support for expansion. In June 2015, the legislature passed a bill containing a financing tool to cover the state’s costs for expansion through the pooling of hospital funds. Additionally, in December state legislators requested the Department of Health and Hospitals to update previous 2013 and 2014 reports on Medicaid expansion options by early January.
South Dakota: Previously Governor Daugaard sought approval for a partial expansion of Medicaid for individuals at or below the federal poverty line (FPL), but federal officials denied this request. In the fall of 2015, the state restarted discussions with federal administrators about expansion options. The state is seeking greater federal reimbursement for Medicaid services provided through Indian Health Services, which would increase funding in the state budget that could be made available to support state expansion costs. In his December budget address the governor indicated support for expanding Medicaid if costs can be covered by the general fund budget.
Utah: Earlier in 2015 it appeared that Utah was close to implementing expansion—in December 2014 Governor Herbert proposed an alternative expansion model, the Healthy Utah Plan, and while this did not gain full legislative approval, a resolution was passed directing state leaders to seek a compromise. However the revised Utah Access Plus proposal was rejected by state legislators in October. In December 2015, the governor’s office indicated that the executive branch does not intend to propose another Medicaid expansion plan and any next steps will be dependent on legislative action. State legislators may consider expansion in 2016, but there are some indications that the legislature may hold off until the presidential election is decided.
Wyoming: At the end of 2014, Governor Mead and the state’s Department of Health released a Medicaid expansion plan, which included premiums and co-payments that could be reduced through healthy behavior activities, as well as a work assistance program. Legislation aligned with the plan was introduced in 2015, but voted down. The governor just released a two-year budget request that includes Medicaid expansion, contending that federal expansion dollars will help the state address budget shortfalls. However some indications are that the majority of state legislators will remain opposed to implementing expansion.
States Seeking Expansion Modifications
A number of states that previously expanded Medicaid are seeking modifications that put requirements on enrollees similar to Indiana’s expansion model, such as premiums and additional cost sharing payments that can be reduced through participation in healthy behavior activities. Arizona is proposing cost sharing above federal thresholds, time limits on coverage, as well as work requirements. However CMS has not approved waivers seeking to include cost sharing above amounts permitted by federal law (one exception being approval for Indiana to charge cost sharing above federal limits for non-emergency use of the ER). CMS has also not approved time limits on coverage and has previously denied waiver requests to condition Medicaid eligibility on work requirements.
Arizona: While Arizona is currently implementing the ACA’s traditional Medicaid expansion, Governor Ducey took office in January 2015 and is seeking a federal waiver to pursue the proposed AHCCCS CARE plan. The plan includes health savings accounts and would require enrollees to pay premiums and co-payments that could be reduced through healthy behavior activities. Similar to Indiana’s approved waiver, the waiver seeks to implement cost sharing above federal limits for non-emergency use of the ER and proposes to disenroll and impose a lock out period for individuals above 100 percent FPL for non-payment of required cost sharing. However, the state is also seeking to implement elements not seen in other waivers, such as requirements that enrollees must be working, attending school, a training program, or actively seeking employment; and limiting lifetime enrollment in the program for able-bodied adults to five years.
Arkansas: The Arkansas Health Care Independence Program, also know as the “Private Option”, was the first Medicaid expansion waiver approved under the ACA, which uses Medicaid funds as premium assistance to provide coverage for newly eligible adults through qualified health plans (QHPs). The state later sought, and was granted, a waiver amendment allowing the creation of health savings accounts, which enrollees pay into to cover co-payments. In early 2015 newly sworn in Republican Governor Hutchinson created a legislative task force to provide recommendations on the future of the state’s expansion model. In December the state announced plans to submit a waiver amendment to continue the program past its current end date of December 2016, which may include changes the task force is considering, such as enhanced cost sharing, a work referral program, and measures to promote employer-sponsored insurance. The governor also recently suggested adding an asset test and lifetime benefit limits to the Private Option, and in December the task force endorsed the governor’s plan to seek changes to the waiver.
Iowa: In 2014 the state expanded Medicaid through the Iowa Health and Wellness Plan, enrolling newly eligible adults with incomes above 100 percent FPL in exchange coverage using Medicaid funds as premium assistance, and providing Medicaid managed care plan coverage for lower-income and medically frail individuals. Both groups have income-based premiums that can be reduced if certain healthy behavior standards are met. However, in late 2014, one of the two participating QHPs withdrew from the exchange, and soon after, the other plan indicated it would no longer accept new Medicaid members. With a lack of QHP options, coverage through the premium assistance model became voluntary. Consequently in September 2015 Iowa submitted a waiver amendment to require all individuals eligible for the expansion to be enrolled in Medicaid managed care plans beginning in 2016.
Ohio: The state has implemented the traditional ACA Medicaid expansion, but the FY2016-FY2017 budget bill HB 64 proposed the Healthy Ohio program, which would require certain Medicaid recipients to contribute to state-run health savings accounts to cover care costs. Governor Kasich signed the budget bill into law in June. The plan to make changes to the existing expansion will require federal approval.
Other Notable State Updates from 2015
Alaska: Soon after taking office in December 2014, Governor Walker and the Department of Health and Social Services released a concept for expanding and reforming Medicaid through the Healthy Alaska Plan. The majority of state legislators were strongly opposed to expansion and legislation did not move forward despite two special sessions. In July 2015 the governor announced his plans to expand Medicaid using executive authority, even though the legislature restricted the executive branch’s authority to expand Medicaid (deemed unconstitutional by some legal analyses). In August the state legislature indicated that it plans to sue the governor for expanding without legislative approval. However the Alaska Supreme Court ruled that despite the ongoing lawsuit, expansion could move forward and individuals began enrolling in September.
Michigan: The state’s original Medicaid expansion waiver that was effective in April 2014, the Healthy Michigan Plan, requires all newly eligible adults to contribute to health savings accounts that are used for required co-payments. Individuals with incomes above 100 percent FPL also are required to make monthly premium contributions, which can be reduced through participation in certain healthy behavior activities. However state law authorizing the expansion required Michigan to submit a waiver amendment, which CMS approved last week (required to prevent the expansion from ending in April 2016). Under the waiver amendment’s special terms and conditions, in April 2018, non-medically frail beneficiaries with incomes above 100 percent FPL will choose to either move to a marketplace option or remain in the Medicaid delivery system. Premiums for both groups cannot exceed two percent of income, and failing to make contributions is not a condition of eligibility for those who must pay premiums. Total cost sharing must follow federal Medicaid rules (the waiver amendment had proposed total cost sharing up to seven percent of income). Individuals who stay in the Medicaid delivery system will be required to engage in certain healthy behaviors that can reduce cost sharing. The state will revise its health behavior protocols in 2017.
Montana: Governor Bullock’s FY2016-17 budget included expansion through the Healthy Montana Plan. While the legislature did not pass the governor’s plan as proposed in legislation, it did pass the HELP Act, which was signed by the governor in April 2015. In September the state submitted a waiver to implement the HELP program, which includes co-payments and premiums, with disenrollment for individuals above poverty for nonpayment after a grace period (re-enrollment can occur relatively soon after certain conditions are met). CMS approved the waiver in November, and coverage for enrollees will be effective in January 2016.
Pennsylvania: When Governor Wolf took office in January 2015, the state had just expanded Medicaid through a waiver for the Healthy PA plan implemented under the previous administration. The plan had included some of the same elements found in other expansion waivers, such as premiums that could be reduced through participation in healthy behavior activities and cost sharing. As promised during his campaign, Governor Wolf transitioned Pennsylvania’s waiver to a traditional Medicaid expansion program, HealthChoices, with coverage effective in September.
The Affordable Care Act created new opportunities for health centers and primary care associations (PCA) to play a leading role in supporting outreach and enrollment into new and expanded health coverage programs. Health centers and PCAs received new funding, sometimes from multiple state and federal entities, new training and tools, and a new mandate to find and enroll eligible individuals, both within their patient caseload and in the broader community. In undertaking this charge, many health centers and PCAs found themselves engaging new partners, building stronger relationships with state Medicaid and insurance or exchange agencies, and often playing a central role in coordinating outreach and enrollment activities in their state or community.
To better understand the new roles of these entities and identify promising strategies in their coordination with state Medicaid and insurance/exchange agencies, NASHP undertook a case study review of Kentucky and Montana, two states with strong enrollment performance where the state PCA and health centers played an important role. With support from the Health Resources and Services Administration’s National Organizations of State and Local Officials Cooperative Agreement, NASHP interviewed representatives from the PCA, a health center, and a Medicaid agency in each state about their respective roles in and coordination of outreach and enrollment assistance during the first two years of Affordable Care Act implementation.
Findings from these interviews are summarized here, with case studies highlighting each state’s circumstances and experiences, followed by a discussion of common themes relating to collaboration with state and federal agencies, lessons learned, and future priorities for outreach and enrollment work with states.
Primarily for internal use, the Montana Department of Public Health and Human Services has developed an ACA Playbook providing resources related to outreach, eligibility, and enrollment; training tools for navigators, assistors, field offices, and other policy workers; and other documents regarding the implementation of the Affordable Care Act in Montana.
Affordable Care Act (ACA) General Information
- “How the Health Care Law is Making a Difference for People of Montana: ACA Overview”
- “Are you ready? The Healthcare Insurance Marketplace is Coming”
- “How the Marketplace Works”
- “What is Medicaid?”
- “Key Information about the Health Insurance Marketplace”
- “Raising Awareness of the Marketplace – How you can help in Montana”
- “Marketplace Application Checklist”
- “What does the Affordable Care Act mean to Montana OPA?”
- “ACA and You – Do Nothing”
- “Native Americans and ACA”
- “Frequently Asked Questions (FAQs)”
- Application Selection Scenarios
- Application Processing Flow Charts
- Streamlined Application
- Customer Service FAQ Scripts
- Field Office Managers’ In-person Training
- Navigator Training Overview
- General ACA Overview Training – Montana Intra-governmental
Tips and Tools
- Step by Step Issue Escalation Guide
- Glossary of Health and Medical Terms
- ACA & Health Coverage Terminology
- Field Staff FAQ’s
- ACA Federal Business Cards
- Federal & National Resources
- ACA Quick Reference
- Montana: Health Center Outreach & Enrollment Assistance
- ACA FAQ Field Script
- Site Support for Field Offices
- Worker Attestation Form