Medicaid Benefits « » The Henry J. Kaiser Family Foundation

General Information - About Medicaid Benefits

Federal Medicaid laws and regulations have historically allowed each of the fifty states, the District of Columbia and the five U.S. territories: American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the Virgin Islands substantial flexibility to design their own benefits packages subject to certain minimum requirements. Other services may be offered, at a state’s option, if approved by CMS. Mandatory coverage includes:

• Inpatient hospital services, excluding services for mental disease
• Outpatient hospital services
• Federally qualified health center services
• Rural health clinic services (if permitted under state law)
• Laboratory and x-ray services rendered outside a hospital or clinic
• Nursing facility services for beneficiaries age 21 and older
• Physician services
• Certified pediatric and family nurse practitioner services (when licensed to practice under state law)
• Nurse mid-wife services
• Medical and surgical services of a dentist
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children
• Family planning services and suppliesHome health services for beneficiaries who are entitled to nursing facility services under the state’s Medicaid plan, including intermittent or part-time nursing services, home health aide services and medical supplies and appliances for use in the home
• Pregnancy-related services and services for other conditions that might complicate pregnancy, as well as postpartum care for 60 days
• Tobacco Cessation Services for Pregnant Women (beginning October 1, 2010)
• Freestanding Birthing Center Services (if licensed or otherwise recognized by a State)

See the service-specific footnotes for additional information.

Beyond these minimum requirements, states have had discretion in choosing which services to offer and the scope and range of the services. With passage of the Deficit Reduction Act (DRA) of 2005 states were given the option to implement alternative benefit packages for certain Medicaid beneficiaries, based on benefits in employer-sponsored insurance plans, which could be more limited than the traditional Medicaid benefit package. The DRA also included language permitting states to impose higher cost sharing in certain instances. The parameters of each state’s Medicaid program must be reflected in its State Plan for Medical Assistance and approved by the Centers for Medicare & Medicaid Services (CMS). States may also request waivers of certain requirements in law in order to cover additional populations, to vary their benefit packages by population served or to change the manner in which services are delivered.

General Information - About this Data Collection

The data were compiled by Health Management Associates from Medicaid State Plans and State Plan Amendments as well as from state Medicaid websites and then sent to Medicaid officials in the respective jurisdictions for validation. These tables reflect services, limitations and reimbursement methodologies in effect at five specific points in time – January 1, 2003, October 1, 2004, October 1, 2006, October 1, 2008 and October 1, 2010. For each point in time, there are tables for all fifty states, the District of Columbia and the five U.S. territories: American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the Virgin Islands. The source documents were Medicaid State Plans and State Plan Amendments submitted to and approved by the Centers for Medicare & Medicaid Services (CMS). Additional information was obtained from state websites. From this information, state-specific summaries were prepared by Esther Reagan at Health Management Associates and sent to Medicaid officials in the respective jurisdictions for validation.  Notes on the structure as well as definitions used throughout the database are included below; please contact Laura Snyder at the Kaiser Commission on Medicaid and the Uninsured with any questions. Every state Medicaid program covers certain population groups that are defined in federal law as mandatory; often these groups are collectively called the Categorically Needy (CN) although technically coverage of some CN populations is optional. States may also cover additional groups at their option; these groups are often collectively called the Medically Needy (MN) although a subset also bears the name and, as previously indicated some CN populations are optional. For simplicity, if a state only covers the mandatory population groups, the acronym CN appears. If the state has chosen to cover any of the optional population groups, the acronym MN also appears, however the specific groups covered are not identified. States with waivers may have their Medicaid populations identified differently on the tables. See the state-specific footnotes for additional information. The mandatory coverage groups are primarily:

• Low-income families with children receiving cash assistance through the Temporary Assistance for Needy Families (TANF) program or who meet the requirements of the Aid to Families with Dependent Children (AFDC) program that were in effect in July 1996 before passage of the TANF block grant welfare reform law
• Persons receiving Supplemental Security Income (SSI) benefits in most states
• Pregnant women and children with family income below specified levels
• Children receiving foster care and adoption assistance under Title IV-E of the Social Security Act
• “Dual eligible” beneficiaries (also called Qualified Medicare Beneficiaries or QMBs)
• Special protected groups including certain working disabled beneficiaries and former recipients of SSI benefits

The most common optional coverage groups include:

• The Medically Needy group – individuals who do not meet the financial standards to qualify them for program benefits through a mandatory coverage group but may qualify by “spending down” – incurring medical bills that reduce their excess income and/or resources to qualifying levels
• The Poverty Level group – also called the Aged and Disabled group – individuals over age 65 or with a disability who have low income but do not qualify under a mandatory coverage category
• The Medicaid “buy-in” group, i.e., disabled adults participating through authority in the Balanced Budget Act of 1997 or the Ticket to Work and Work Incentives Improvement Act (TWWIIA)
• The Special Income group – individuals receiving care in an institutional setting such as a nursing facility or Intermediate Care Facility for the Mentally Retarded / Developmentally Disabled (ICF/MR) or alternatively in a home and community-based services waiver program and who are not otherwise Medicaid eligible
• Individuals who require hospice care, have low income but do not qualify under another Medicaid coverage category
• The TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) group – children needing institutional care who may be served in their homes for lower cost and whose family income is not counted
• Pregnant women with income above the threshold for mandatory coverage but below a federally-specified higher income level
• Breast and Cervical Cancer Treatment Program participants

With the exceptions noted in the tables, the information represents a state’s policies applicable to adult Medicaid beneficiaries receiving care on a “fee for service” basis. It was not feasible to include the nuances associated with coverage and limitations for care provided by the many contracted managed care organizations operating within the states because, in some cases, they are allowed to use different coverage and reimbursement policies. To the extent possible, distinctions affecting coverage, limitations and copayment requirements have been made in the tables for states with research and demonstration waivers. See the state-specific footnotes for additional information. The information in these tables does not reflect policies relative to separate State Children’s Health Insurance Programs (SCHIP or CHIP).  If a “No” appears in the “Is the Benefit Covered?” column on a table, the service is not covered for adults in the particular state as of the specific point in time or the state does not allow direct reimbursement to the provider type although the service may be covered when billed by another provider, e.g., therapy services provided in an institutional setting. The “Copayment Requirement” field on a table is blank unless the state requires a copayment for that service. The state-specific footnotes may provide additional information regarding copayment requirements. Other fields may be blank unless the state has identified a specific and noteworthy characteristic beyond those in the state or service-specific footnotes.   Although a particular service may not be identified on a table as covered, the state is obligated by federal law to provide it for a child if it has been determined medically necessary through an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening (e.g., a well-child exam) and the state agrees with that determination. States establish prior approval requirements for many individual procedures, items or circumstances to assure medical necessity and appropriate utilization of funds. Identification of every prior approval requirement on these tables was not feasible so only selected requirements appear. The service-specific footnotes reference other common prior approval requirements. An exception to any coverage limitation cited would require prior approval by the state Medicaid agency.      

Glossary

ADL: Activities of Daily Living – describes an individual’s need for Personal Care services

APC: Ambulatory Payment Classifications – a methodology used by the Medicare program and a number of state Medicaid programs to group outpatient hospital services that are similar clinically and in terms of the resources they require such that an all-inclusive payment may be made

APG: Ambulatory Patient Group – a methodology similar to 

APCs used to group and reimburse outpatient hospital services

ASA: American Society of Anesthesiologists – an organization setting base rates for anesthesia services that some states use

ASC: Ambulatory Surgery Center

AWP: Average Wholesale Price – a term used in prescription drug pricing

BBA: Balanced Budget Act of 1997 – a federal law providing states an option to cover working disabled persons

CN: Categorically Needy 

CRNA: Certified Registered Nurse Anesthetist

DAW: Dispense As Written – a term related to the dispensing of prescription drugs

DME: Durable Medical Equipment

DRG: Diagnosis Related Groups: a per-discharge reimbursement methodology that bases payment on the patient’s age, primary diagnosis and procedures rendered during an inpatient hospital stay

EPSDT: Early and Periodic Screening, Diagnosis and Treatment

FUL: Federal Upper Limit – a term used in prescription drug pricing

ICF/MR: Intermediate Care Facility for the Mentally Retarded/Developmentally Disabled

ICU:  Intensive Care Unit 

IMD: Institution for Mental Diseases – a hospital or nursing facility for inpatient treatment of persons with mental illness

LOC: Level of Care

LOS:  Length of Stay

LTACH: Long-Term Acute Care Hospital

LTC: Long-Term Care 

SMAC/MAC: (State) Maximum Allowable Cost – a term used in prescription drug pricing

MN: Medically Needy

MSW: Medical Social Worker

OT: Occupational Therapy

OTC: Over the Counter, as in drugs available without a prescription

PDL: Preferred Drug List

PIHP: Prepaid Inpatient Health Plan – an entity that provides specialty services, often related to mental health and substance abuse that are generally reimbursed on a capitation basis

PRTF: Private Residential Treatment Facility

PT: Physical Therapy

RBRVS: Resource Based Relative Value Scale – often used in setting reimbursement rates for physician services

RHC: Rural Health Clinic

RN: Registered Nurse 

Rx: Prescription

SBIRT: Screening, Brief Intervention and Referral for 

Treatment – a term used relative to substance abuse services

SP: Speech Pathology – sometimes called Speech Therapy 

TWWIIA: Ticket to Work and Work Incentives Improvement Act – a federal law providing states an option to cover working disabled persons

WAC: Wholesale Acquisition Cost – a term used in prescription drug pricing

Year: May refer to calendar year, state fiscal year, contract year or any other 12-month period. 

State and Territory-Specific Footnotes

Alabama: This State imposes its copayment requirements on dually eligible Medicare and Medicaid beneficiaries for services for which the State is asked to pay the coinsurance and/or deductible amount. The State does not require a copayment for physician office visits during which surgical procedures are performed. Any identified copayment requirements are applicable to beneficiaries age 18 and older. This state no longer has any operating Institutions for Mental Diseases (IMDs).

Alaska: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL) established for the State (the FPL for the state is 25 percent higher than in the 48 contiguous states and the District of Columbia). Beneficiaries in this group with income above the FPL must pay an income-based monthly premium. Any identified copayment requirements are applicable to beneficiaries age 18 and older.

Arizona: This State has an approved Section 1115 Waiver from CMS under which it provides services in a program called the Arizona Health Care Cost Containment System (AHCCCS). The program includes an Acute Care program and a companion program for long-term care services (in institutional and alternative residential settings as well as home and community-based care) called the Arizona Long-Term Care System (ALTCS). All Acute Care program members, whether receiving care on a fee for service basis or through enrollment in a managed care organization, are eligible for the same array of acute care services. All ALTCS members, whether receiving care on a fee for service basis or through enrollment in a managed care organization, are eligible for the same array of acute and long-term care services. The State currently covers pregnant women if family income is at or below 150 percent of the federal poverty level (FPL), infants up to age one if family income is at or below 140 percent of the FPL, and children from age one through five years if family income is at or below 133 percent of the FPL. The State includes the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the FPL. Beneficiaries in this group with monthly income above $500 pay an income-based monthly premium. The majority of the State’s Medicaid beneficiaries are enrolled in contracted managed care organizations through which they receive health care services. The copayment requirements shown on the tables apply to the traditional Medicaid population as permitted in federal law. Copayment requirements for the Transitional Medical Assistance (TMA) and AHCCCS expansion populations are higher and not reflected on the tables; these groups may be denied non-emergency services for failure to pay the required copayments. Any identified copayment requirements are applicable to beneficiaries age 19 and older. Providers are required to obtain prior approval from the AHCCCS Administration for specified services for the fee for service populations or from the State’s contracted managed care organizations for the managed care populations. Major differences in coverage limitations between the Acute Care program and the ALTCS program are noted on the tables. The tables reflect that Home and Community-Based Services (HCBS) Waivers are not covered. This does not mean that such services are not offered by the State, only that they are not covered through a Section 1915(c) waiver and are instead covered through Arizona’s Section 1115 waiver.

Arkansas: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group are not required to pay monthly premiums but are required to make a copayment for most services received. These copayment amounts are not reflected on the tables but are generally $10 per service or a percentage of the program’s payment for a particular service. This State also has an approved Section 1115 HIFA Waiver from CMS under which it provides a safety net health benefit package in partnership with employers to parents and spouses of Medicaid and CHIP children and to childless adults and spouses. The individuals must be between the ages of 19 and 64 with income at or below 200 percent of the FPL. This population receives a limited benefit package under a plan called ARHealthNetworks (also called ARHealthNet), which places limits on services, such as the number of covered prescriptions per month and the number of covered physician office visits and hospital services per year. There is a $100 annual deductible, copayments are set at 15 percent of allowed charges for each covered service and there is a maximum annual benefit of $100,000. The maximum out of pocket cost per year is $1,000. The information provided in the tables does not reflect policies applicable to this limited benefit program.

California: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group must pay an income-based monthly premium. Irrespective of the amounts shown on the tables, copayments are not required for any service for beneficiaries younger than age 19 or for which the program’s payment is $10.00 or less. This State has an approved Section 1115 Waiver through which health care coverage, in advance of health care reform requirements in 2014 will be extended to two groups of low-income adults otherwise ineligible for Medicaid at the option of each county – the Medicaid Coverage Expansion (MCE) adults, which refers to non-pregnant adults between ages 19 and 64 who are not enrolled in Medicaid or CHIP and have incomes at or below 133 percent of the FPL (or a lower threshold set by the county) and the Health Care Coverage Initiative (HCCI) adults which refers to non-pregnant adults between ages 19 and 64 with incomes between 133 percent and 200 percent of the FPL (or a lower threshold set by the county). The information provided in the tables does not reflect policies applicable to this limited benefit waiver, called Bridge to Reform.

Colorado: This State has an approved Section 1115 HIFA Waiver from CMS, relying on federal CHIP authority, under which it extends Medicaid eligibility to pregnant women with family income at or below 200 percent of the federal poverty level (FPL). The State also received federal Medicaid State Plan approval to implement a hospital provider fee program that enabled Medicaid eligibility expansion to parents with income below 100 percent of the FPL. Additional expansions are planned. Any identified copayment requirements are applicable to beneficiaries age 19 and older. Providers may collect multiple copayments, if applicable, on the same date of service, e.g., a hospital could collect a copayment for both an outpatient visit and a laboratory service. Substance abuse treatment for pregnant women can extend up to 12 months post partum if services were initiated prior to delivery.

Connecticut: This State was the first in the country to implement the childless adult coverage option available under the Patient Protection and Affordable Care Act (ACA) of 2010 and provides full Medicaid benefits to these beneficiaries if their income is at or below 56 percent of the federal poverty level (FPL). The State also provides full benefits to parents and caregivers of Medicaid eligible children with income at or below 185 percent of the FPL and to pregnant women with income at or below 250 percent of the FPL. The State added the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their earned income is at or below $75,000 per year. Beneficiaries in this group with income above 200 percent of the FPL pay a monthly premium.

Delaware: This State has an approved Section 1115 Waiver from CMS under which it extends Medicaid eligibility to additional low-income adults through savings achieved by implementing a managed care program called the Diamond State Health Plan. This statewide managed care program utilizes both a capitated plan and an enhanced fee for service plan, the latter administered by the State and called Diamond State Partners. Most Medicaid beneficiaries, including the expansion population of adults age 19 and older with income at or below 100 percent of the federal poverty level (FPL), are required to enroll in one of the two managed care plans. The expansion population is not entitled to coverage of any services until the effective date of such enrollment. In addition to services provided through the managed care plans, beneficiaries receive certain wrap-around services on a fee for service basis. The wrap-around services covered for the expansion population are generally the same as those available to the Traditional Medicaid population. The State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 275 percent of the FPL; however those with income above 100 percent of the FPL are required to pay an income-based monthly premium. The tables reflect services available through both the managed care plans and as a wrap-around benefit. The capitated plan may also provide additional services for its members. Delaware does not offer Rural Health Clinic services as there are no such clinics located in the state.

District of Columbia: The District implemented the childless adult coverage option available under the Patient Protection and Affordable Care Act (ACA) of 2010 and provides full Medicaid benefits to these beneficiaries if their income is at or below 133 percent of the federal poverty level (FPL). Also using this authority, the District extends Medicaid eligibility to additional low-income, non-disabled adults between the ages of 50 and 64 with income at or below 50 percent of the FPL who are not custodial parents or caretakers of children under age 19. The District has extended Medicaid eligibility to working disabled adults with HIV/AIDS, permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA); qualified beneficiaries must have income at or below 300 percent of the FPL. The benefit package, managed care delivery system and cost sharing requirements for these beneficiaries are the same as for the Traditional Medicaid population. No premium is required. The table for the District does not reflect coverage of Rural Health Clinics because there are none located there.

Florida: This State has an approved Section 1115 Waiver from CMS under which certain Medicaid eligibility groups are required to enroll in and receive health care services from specified health plans. At this time, the waiver is limited to five counties – Baker, Broward, Clay, Duval and Nassau. The health plans are paid a risk-adjusted premium and are required to provide all mandatory and most optional Medicaid benefits, but covered services may vary in amount, duration and scope. The waiver includes a provision for the enhanced benefit account program, which is designed as an incentive program to promote and reward participation in healthy behaviors. Beneficiaries enrolled in a demonstration health plan that practice specified healthy lifestyle behaviors may use available credits (up to $125 per year) to purchase approved health-related products and supplies at any Medicaid participating pharmacy. The waiver also includes a provision to allow beneficiaries who have access to employer-sponsored insurance (ESI) to opt out of Medicaid and select an ESI plan. Because the reform authorized under the waiver has only been partially implemented, the tables reflect services available on a fee for service basis for the Medicaid population not yet included under the waiver.

Georgia: This State added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium.

Hawaii: This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extends Medicaid eligibility to a number of previously uninsured individuals and through which care is delivered by managed care organizations. The waiver program, commonly called QUEST Expanded, has multiple components, including QUEST, QUEST Expanded Access (QExA), QUEST-ACE (Adult Coverage Expansion) and QUEST-Net, for different populations at different income levels and with different health care needs. The QUEST component includes non-pregnant adults, including childless adults up to an enrollment limit, with income at or below 100 percent of the federal poverty level (FPL), pregnant women with income at or below 185 percent of the FPL and children in families with income at or below 300 percent of the FPL. The QExA component covers elderly, blind and disabled beneficiaries and, in addition to the primary and acute care services available in QUEST, QExA also covers nursing facility and home and community-based care. The QUEST-Net and QUEST-ACE components cover adult expansion populations and offer more restrictive benefit packages, which are not reflected on the tables. All dental care is provided on a fee for service basis outside of the QUEST Expanded health plans. Copayments are not required from any beneficiaries. Hawaii has not chosen to use the authority of the Ticket to Work and Work Incentives Improvement Act (TWWIIA) to offer Medicaid benefits to the working disabled. Note that the FPL for Hawaii is 15 percent higher than in the 48 contiguous states and the District of Columbia.

Idaho: This State was one of the first to receive approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005. Idaho has implemented its Medicaid Basic Plan with services designed for healthy children and adults; this plan does not include long-term care, organ transplants or intensive mental health treatment, and most beneficiaries are enrolled in the State’s Primary Care Case Management model of managed care called Healthy Connections. The Medicaid Enhanced Plan provides services designed for beneficiaries with more complex health care needs such as the elderly and disabled and includes long-term care in institutional and community settings, organ transplants and intensive mental health treatment. Children with higher income enrolled in the Basic Plan are subject to a monthly premium. A third plan, the Medicare-Medicaid Coordinated Plan, provides integrated care for beneficiaries dually eligible for Medicare and Medicaid. The tables do not reflect all coverage variances across plans but do identify those benefits covered by at least one of the plans. This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 500 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 133 percent of the FPL pay an income-based monthly premium.

Illinois: This State received approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005. The State extends Medicaid eligibility to parents and caretaker relatives of Medicaid-eligible children with income at or below 200 percent of the federal poverty level (FPL). The program is called FamilyCare and has four components. The first component, FamilyCare Assist is for beneficiaries with income below 133 percent of the FPL; these beneficiaries receive full Medicaid benefits. The second component, FamilyCare Share, is for beneficiaries with income below 150 percent of the FPL; these beneficiaries also receive full Medicaid benefits. The third component, FamilyCare Premium, is for beneficiaries with income below 185 percent of the FPL; these beneficiaries also receive full Medicaid benefits but are required to pay an income-based monthly premium. Beneficiaries in all three of these groups are required to pay any specified copayments for services received. The fourth component, FamilyCare Rebate, which is 100 percent state-funded, is a premium assistance program for beneficiaries with income below 200 percent of the FPL. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 350 percent of the FPL. Beneficiaries in this group with income above 100 percent of the FPL pay an income-based monthly premium and all beneficiaries are required to pay any specified copayments for services received.

Indiana: This State has an approved Section 1115 waiver from CMS through which it operates two distinct health insurance products: the Hoosier Healthwise Program for current Medicaid eligible beneficiaries and the Healthy Indiana Plan (HIP) for uninsured adults not currently eligible for Medicaid. The Hoosier Healthwise program provides coverage for children, pregnant women and low-income families. The Traditional Medicaid Program serves primarily beneficiaries dually eligible for Medicare or eligible for Medicaid through satisfaction of a spend down as well as beneficiaries receiving care in an institution. One other program, called Care Select, is the State’s disease management program for Medicaid beneficiaries with chronic illnesses such as asthma and diabetes. The majority of Hoosier Healthwise enrollees as well as beneficiaries in the Traditional Medicaid and Care Select Programs receive full and comparable benefits; only these benefits are reflected on the State’s tables. Benefits related to the HIP are not reflected on the tables. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 350 percent of the FPL. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. Any identified copayment requirements on the tables are applicable to beneficiaries age 18 and older.

Iowa: The Medicaid program in this state is administered through the Iowa Medicaid Enterprise (IME), which is a collection of approved contracts with proven specialty providers of administrative support services. The contracts are overseen by Medicaid agency staff. The state has three expansion population coverage plans. Iowa was the first state to take up the Home and Community-Based Services (HCBS) option that allows states to offer HCBS services as a State Plan benefit rather than through a Section 1915(c) Waiver. The state used the option to add case management and habilitation services to a targeted population under the 1915(i) provision – persons with a history of mental illness who also meet certain risk factor criteria and have ongoing needs. Iowa also has an approved Section 1115 Waiver from CMS under which it extends Medicaid eligibility to a number of previously uninsured individuals not otherwise eligible for Medicaid. The waiver program, called IowaCare, covers individuals between the ages of 19 and 64 with family income at or below 200 percent of the federal poverty level (FPL), including parents of children receiving Medicaid or CHIP benefits. The program also covers pregnant women and their newborns with income up to 300 percent of the FPL who spend down to 200 percent. The Medicaid expansion program covers children through age 18 diagnosed with serious emotional disabilities and meeting criteria for institutionalization but able to be cared for in the community where necessary services can be provided within the scope of the waiver. All three expansion groups receive a limited benefit package and are restricted to selected providers for service. They are also subject to copayments for services, and those with income above 150 percent of the FPL are required to pay income-based monthly premiums. The information provided in the tables does not reflect this limited benefit package. Iowa has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. This State imposes a $1 copayment requirement on dually eligible Medicare and Medicaid beneficiaries for each date of service for which the State is asked to pay the coinsurance and/or deductible amount on a Medicare Part B benefit.

Kansas: This State has added the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 100 percent of the FPL pay an income-based monthly premium. The copayment requirement for physician services is applicable to and in addition to any amount payable to hospitals for outpatient services. This State imposes a $2 copayment requirement on dually eligible Medicare and Medicaid beneficiaries for each date of service for which the State is asked to pay the coinsurance and/or deductible amount.

Kentucky: This State was one of the first to receive approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005. Kentucky’s KyHealth Choices initiative customizes beneficiaries’ benefits to meet their specific needs. There are four plans included in the initiative. Global Choices (“A” on the tables) includes the standard benefit package with more extensive cost sharing and benefit caps and does not include long-term care; it targets pregnant women and parents, caretaker relatives, recipients of cash assistance through SSI or the state’s TANF (KTAP) program, women with breast or cervical cancer, medically fragile children and children in foster care. This plan also includes the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These disabled beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 100 percent of the FPL pay an income-based monthly premium. Family Choices (“B” on the tables) is targeted to children, including those eligible for Traditional Medicaid and those covered by both the Medicaid expansion and separate CHIP (called KCHIP in Kentucky); it includes the standard benefit package with no cost sharing for the Medicaid-covered children. Optimum Choices (“C” on the tables) includes the standard benefit package as well as institutional (ICF/MR) and community-based long-term care; it targets persons with developmental disabilities. The fourth plan, Comprehensive Choices (“D” on the tables), targets the elderly and disabled in need of institutional or community-based long-term care; it includes the standard benefit package as well as long-term care services, and also relies on authority in a Section 1915(c) waiver. Irrespective of the plan, members are subject to copayments for certain services and have both a medical and a pharmacy out of pocket maximum of $225 per year. The plan’s designated letter on the tables notes distinctions in coverage; nuances applicable only to the separate KCHIP are not included. Any identified copayment requirements are applicable to beneficiaries age 18 and older and do not apply to preventive services; beneficiaries eligible for both Medicare and Medicaid are exempt from cost sharing.

Louisiana: Currently most of this State’s Medicaid beneficiaries receive their care on a fee for service basis through a Primary Care Case Management model of managed care called CommunityCARE. This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL) and they meet the established resource limit. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium.

Maine: MaineCare is the name of the health care program in this State that provides coverage for residents living below 100 percent of the federal poverty level (FPL) as well as others with low-income. The Medicaid program is a part of MaineCare as is the State’s CHIP, called CubCare, for which some of its members with higher family income are required to make nominal monthly premiums. Maine has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the FPL. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. Most MaineCare beneficiaries receive their care through a Primary Care Case Management model of managed care but may voluntarily enroll in DirigoChoice, a managed care entity, if they work for an eligible business. The State has an approved Section 1115 HIFA Waiver from CMS under which it extends Medicaid eligibility to childless adults with income at or below 100 percent of the FPL. This population receives a limited benefit package that is not referenced in the tables.

Maryland: This State has an approved Section 1115 managed care waiver from CMS under which it extends Medicaid eligibility to a number of different populations not otherwise eligible for Medicaid in a program called HealthChoice. This includes offering a limited benefit package of primary care benefits to beneficiaries in the Primary Adult Care (PAC) program for childless adults with income at or below 116 percent of the federal poverty level (FPL). Pharmacy copayments for PAC are set at higher levels than for beneficiaries receiving full benefits. The waiver also includes the State’s expansion population eligible for family planning benefits only. The 1115 waiver allows the State to provide enriched benefits such as therapies, dental care and private duty nursing to certain Medicaid eligible disabled adults in a program called the Rare and Expensive Case Management (REM) program. Services for HealthChoice members are provided primarily through managed care organizations. The State has also added the optional Medicaid buy-in group of working disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are covered through State Plan authority and are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the FPL. All of these beneficiaries must comply with applicable HealthChoice copayment requirements and an income-based semi-annual premium is charged for those with income above 100 percent of the FPL. The information provided in the tables does not reflect policies applicable to any limited benefit programs.

Massachusetts: The Commonwealth’s MassHealth program includes both Medicaid and CHIP and operates in part under an approved Section 1115 Waiver from CMS that includes expansion populations. Under the waiver, health care coverage and insurance premium assistance has been extended to a number of previously uninsured individuals. There are many coverage types under MassHealth including – Standard, CommonHealth, Family Assistance, Basic, Essential, Limited and others – each targeting a different population and with different eligibility requirements. These populations include low-income workers and their families, working and non-working disabled persons, individuals with HIV/AIDS and women with breast or cervical cancer. The waiver also covers long-term unemployed adults and children in families with income at or below 200 percent of the federal poverty level (FPL). Individuals age 65 or older or institutionalized are not eligible under the 1115 waiver but are covered through the Medicaid State Plan. Some MassHealth members are required to pay monthly premiums, and copayments for members are limited to annual maximums of $200 for prescription drugs and $36 for non-pharmacy services per beneficiary. Services for members under age 65 are generally provided by managed care organizations (MCOs) or MassHealth’s Primary Care Clinician Plan. Those members who choose to enroll in MCOs receive some of their services on a fee for service basis from MassHealth contracted direct service providers. Only policies applicable to all MassHealth enrollees or related to those services reimbursed on a fee for service basis directly by the Commonwealth are reflected on the tables. Some service limitations may apply depending on beneficiary age and coverage type.

Michigan: The inpatient hospital copayment requirement does not apply to second hospitals receiving a transfer or to readmissions within 15 days of discharge for the same DRG/diagnosis. The physician copayment requirement is limited to specific office visit codes and does not include mental health services. Services in an Intermediate Care Facility for the Mentally Retarded are indicated as non-covered because the State has now closed all such facilities. This State has an approved Section 1115 waiver from CMS through which it extends Medicaid coverage for a limited package of benefits to non-pregnant childless adults between the ages of 19 and 64. Called the Adult Benefits Waiver, the program was previously authorized under Title XXI and is available during open enrollment periods only to qualifying individuals with income at or below 35 percent of the federal poverty level (FPL). Copayments for selected services are required and are higher than for the Traditional Medicaid population. The Adult Benefits Waiver population receives a limited benefit package that is not referenced on the tables.

Minnesota: This State’s Traditional Medicaid population of categorically and medically needy beneficiaries receives full benefits and is identified on the tables as “A.” Also included in the “A” population on the tables is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These disabled beneficiaries are allowed to continue Medicaid coverage and receive full benefits irrespective of annual income, however they are responsible for applicable copayments and an income-based monthly premium is required. Minnesota has an approved Section 1115 Waiver from CMS under which it extends Medicaid eligibility to a number of previously uninsured individuals with income at or below 275 percent of the federal poverty level (FPL), including children, pregnant women and the parents and caretakers of Medicaid and CHIP-eligible children. The program, called MinnesotaCare, requires monthly premiums based on gross family income and is identified on the tables as “B”. MinnesotaCare children and pregnant women receive the same benefits as the Traditional Medicaid population, so are included within the meaning of group “A” on the tables. Parents and caretakers on MinnesotaCare receive a lesser benefit package and additional copayments apply to this group. They are the “B” population on the tables. MinnesotaCare also provides a limited benefit package to childless adults with income at or below 250 percent of the FPL. These beneficiaries receive the same limited benefit package but have even more copayment requirements, which are not reflected on the tables. Depending on income, some MinnesotaCare parents and childless adults have a $10,000 annual limit on inpatient hospital care; a subset of this group is also responsible for a ten percent copayment up to $1,000 for inpatient care. All MinnesotaCare beneficiaries receive services through managed care organizations.

Mississippi: This State extends Medicaid benefits generally only to populations for which coverage is mandated in federal law. Some optional populations are covered but not the medically needy group. With few exceptions, income limits are those established in federal law.

Missouri: This State’s Medicaid program operates as MO HealthNet. Adult coverage for a number of program benefits is limited to pregnant women and those beneficiaries who are blind or are residing in an institutional setting such as a nursing facility. The State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the federal poverty level (FPL) and they meet the established resource limit. Beneficiaries in this group with income above 100 percent of the FPL pay an income-based monthly premium. Within federal constraints applicable to specific population groups, services and settings, any identified copayment requirements are applicable to beneficiaries age 19 and older, except for the blind. Beneficiaries eligible for both Medicare and Medicaid are exempt from cost sharing if program payment is limited to coinsurance or deductible amounts. The copayment requirement for physician and related services is applicable to and in addition to any amount payable to hospitals or laboratories for services.

Montana: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL) and they pay an income-based monthly cost share. This group along with the rest of the State’s Traditional Medicaid population that receives full benefits is identified on the tables as “A.” The State has an approved Section 1115 Waiver from CMS under which it extends Medicaid eligibility to individuals between the ages of 21 and 64 who are neither pregnant nor disabled and who are parents and caretaker relatives of dependent children. The Basic Medicaid Waiver for Able-Bodied Adults was modeled after the State’s welfare reform demonstration from the mid-1990s and provides mandatory Medicaid benefits as well as a limited package of optional services. Specified services are not covered, including audiology, dental, durable medical equipment, eyeglasses, optometry and ophthalmology for routine eye exams, home infusion, personal care services and hearing aids. However the services are available through the Essentials for Employment program if services are essential to obtaining or maintaining employment, consistent with a typical work-related insurance program. The State provides coverage for emergency dental situations, medical conditions of the eye and certain medical supplies such as diabetic supplies and oxygen. The expansion population covered under the waiver is identified on the tables as “B.” Cost sharing requirements are the same for both groups.

Nebraska: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 200 percent of the FPL pay a monthly premium. Any identified copayment requirements are applicable to beneficiaries age 19 and older. The State does not require a copayment for mental health care, irrespective of the provider of service. The State’s copayment requirements for physicians are not applicable to primary care services and the copayment requirements for nurse practitioners are not applicable to advance practice nurses with specialties in family practice, general practice, pediatrics or internal medicine. The State requires a $1 per visit copayment for occupational therapy and physical therapy and a $2 per visit copayment for speech pathology services rendered in an independent clinic setting but requires a $3 per visit copayment if the services are rendered in an outpatient hospital setting. Participants in some of the State’s Home and Community-Based Services Waivers, who have higher income, are required to pay a monthly premium.

Nevada: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These working beneficiaries are allowed to obtain or maintain their Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level, however they are responsible for a monthly premium.

New Hampshire: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 450 percent of the federal poverty level (FPL), however they are responsible for applicable copayments and an income-based monthly premium is required for those with income above 150 percent of the FPL.

New Jersey: This State has an approved Section 1115 Waiver from CMS under which it extends health care coverage to previously uninsured individuals using both Title XIX and Title XXI funding. The waiver program is called NJ FamilyCare, covers parents and caretaker relatives of Medicaid and CHIP-eligible children with income at or below 200 percent of the federal poverty level (FPL) and also extends coverage to pregnant women with income between 185 percent and 200 percent of the FPL. Under the waiver, pregnant women receive full Medicaid benefits and the parents and caretaker relatives receive a reduced benefit package modeled after a standard commercial plan, which is not reflected on the tables. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 500 percent of the FPL; however an income-based monthly premium is charged based on income above 150 percent of the FPL. Children in families with income between 200 percent and 350 percent of the FPL as well as parents and caretakers with income above 150 percent of the FPL are required to pay both copayments for services, which do not appear on the tables, and income-based monthly premiums. In March 2010, the State imposed a freeze on eligibility for parents and caretaker relatives with earned income over 133 percent of the FPL who are not otherwise eligible for Medicaid. Childless adults were at one time eligible to enroll in NJ FamilyCare with services paid with State dollars only, but are not currently allowed to do so. Benefits available to this State’s Medically Needy population are limited as follows: services in a nursing facility, inpatient psychiatric hospital for persons under age 21, institution for mental diseases, intermediate care facility for the mentally retarded (intellectually/developmentally disabled) and religious non-medical health care institution are not covered at all, nor is hospice care; services in an inpatient hospital setting, as well as chiropractor services and targeted case management are limited to pregnant women; podiatrist services are limited to pregnant women and the aged, blind and disabled; and prescription drug coverage is available only to pregnant women and children in the Medically Needy group.

New Mexico: In addition to providing benefits to the Traditional Medicaid population, this State has an approved Section 1115 Waiver from CMS under which it operates the State Coverage Insurance (SCI) program. Initially authorized in part under HIFA waiver authority and utilizing unspent Title XXI funds, the program has been continued as permitted by CHIPRA with Title XIX funding. The SCI covers parents of Medicaid and CHIP-eligible children as well as childless adults between the ages of 19 and 64 with income at or below 200 percent of the federal poverty level (FPL). These adults receive a benefit package similar to basic commercial coverage, which is more limited than the Traditional Medicaid package, and are required to pay income-based monthly premiums and copayments for some services. Services are generally delivered through contracted managed care organizations and there is an annual benefit limit of $100,000. Unique benefit and copayment information for these two groups is identified on the tables as “A.” Copayments with a range are applied based on the individual’s income. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 if their income is at or below 250 percent of the FPL. These beneficiaries receive full Medicaid benefits but are required to pay income-based monthly premiums and copayments for some services. Unique copayment information for these disabled adults is identified on the tables as “B.” Traditional Medicaid beneficiaries have no copayment requirements. Any items on the tables without an “A” or a “B” reference are applicable to the Traditional Medicaid population and the disabled group to the extent those individuals are receiving care on a fee for service basis. Chiropractic care and private duty nursing are not covered for any adults.

New York: This State has an approved Section 1115 Waiver from CMS under which it implemented The Partnership Plan. The waiver extends health care coverage to low-income adults covered under the former State-funded cash assistance Safety Net program and moved most Medicaid beneficiaries from a primarily fee for service delivery system to a mandatory managed care environment. In 2009 the State implemented its Beneficiary-Specific Utilization Threshold (BSUT) policy and now applies the BSUTs to outpatient hospital, physician and clinic services, including dental and mental health clinics, and to prescription drugs and laboratory services. The BSUTs are applied based on a beneficiary’s physical health condition using a clinical risk group crosswalk. A subsequent waiver amendment created the Family HealthPlus (FHPlus) program for additional low-income uninsured adults under the age of 65. The benefits package for FHPlus beneficiaries is less comprehensive and requires more and higher copayments for services; the FHPlus benefits and copayments are not reflected on the tables. FHPlus does not include long-term care services for the chronically ill, non-emergency medical transportation, most medical supplies or the majority of non-prescription drugs. Limitations apply to home health, rehabilitation and inpatient and outpatient mental health and substance abuse services as well. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits on a fee for service basis, if their income is at or below 250 percent of the federal poverty level.

North Carolina: This State’s Medicaid program delivers services predominantly through a Primary Care Case Management (PCCM) model of managed care called Community Care of North Carolina. The program is a community-based enhanced PCCM model that brings providers together in networks to manage the health care needs of enrolled beneficiaries. Care is provided on a fee for service basis, copayment requirements are applied uniformly within federal constraints and the program is available statewide. Each year the State legislature establishes visit limits applicable to services rendered by specified practitioners; the limits do not apply to certain physician specialties nor are they applicable to pregnant women or beneficiaries enrolled in a community alternatives program providing home and community-based care. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 150 percent of the federal poverty level.

North Dakota: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 225 percent of the federal poverty level (FPL). Beneficiaries are required to pay an enrollment fee of $100 and a monthly premium equal to five percent of their gross countable income. They receive the same benefits as other Medicaid beneficiaries and are subject to the same copayment requirements. Any identified copayment requirements are also applicable to beneficiaries dually eligible for Medicare and Medicaid unless they are institutionalized.

Ohio: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). All identified copayments apply to these beneficiaries, and those individuals with income greater than 150 percent of the FPL are required to pay an income-based monthly premium. Pregnant women are not exempt from the copayments associated with routine eye exams and the fitting of eyeglasses

Oklahoma: This State has an approved Section 1115 Waiver from CMS combining both Title XIX and Title XXI funding under which the SoonerCare program was established to increase access to primary care for members within an enhanced primary care case management delivery system, currently through a Patient-Centered Medical Home model. The waiver has been amended to extend Medicaid eligibility to a number of previously uninsured individuals, including pregnant women and low-income families with children whose income is at or below 185 percent of the federal poverty level (FPL). The State also operates the Insure Oklahoma program under the Section 1115 Waiver, which is authorized to expand coverage to uninsured adults and college students with income up to 200 percent of the FPL. This program provides premium assistance and direct individual state coverage to those uninsured adults who are working for a small business, are self-employed or are unemployed and seeking work. Also included in the Insure Oklahoma program are working disabled adults with an approved Ticket to Work authorized through the federal Ticket to Work and Work Incentives Improvement Act (TWWIIA). Medical benefits under the Insure Oklahoma program are more limited than under SoonerCare and copayment requirements are higher. The State was also approved to implement four Health Access Network (HAN) pilots that offer core components of electronic medical records, improved access to specialty care, telemedicine, expanded quality improvement strategies and care management/care coordination to SoonerCare members with complex health care needs. All SoonerCare members receive the same services and, within federal constraints, are subject to the same cost sharing requirements. This State imposes a $1.00 copayment requirement on dually eligible Medicare and Medicaid members for any service for which the State is asked to pay the coinsurance and/or deductible amount. The information appearing in the tables represents basic SoonerCare adult benefits. Benefits and copayment requirements for the Insure Oklahoma program are not reflected on the tables.

Oregon: This State has an approved Section 1115 Waiver from CMS under which it implemented a prioritized list of covered health services for its Medicaid program, called the Oregon Health Plan (OHP), based on their comparative benefit to the population served. Through an amendment to the waiver implemented in 2003 the State extended Medicaid eligibility to a number of previously uninsured individuals. The Traditional Medicaid population, covered under OHP Plus and identified as “A” on the tables for 2004 and later, includes families with income below 100 percent of the federal poverty level (FPL), the elderly, blind and disabled, and pregnant women and children living in families with income at or below 185 percent of the FPL. Also covered under OHP Plus is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA), some of whom are required to pay a monthly premium. The waiver’s expansion population, covered under OHP Standard and identified as “B” on the tables for 2004 and later, includes adults with income below 100 percent of the FPL not eligible for Traditional Medicaid coverage. The benefit package for the OHP Standard program is more limited than for the OHP Plus program. OHP Standard participants who become pregnant are transferred to the OHP Plus program for the duration of their pregnancy and two months post partum. OHP Plus program participants age 19 and older are required to make copayments for specified services if the program makes any payment, even if Medicare or their private insurance covered part of the cost of the service. Imposition of a copayment requirement on the OHP Standard group has been prohibited as the result of a court order, but this population is required to pay income-based monthly premiums if their income is above 10 percent of the FPL. Services in an Intermediate Care Facility for the Mentally Retarded are indicated as non-covered because the State has now closed all such facilities.

Pennsylvania: This State’s covered services for the Medically Needy (MN) population are more restrictive than for the Categorically Needy (CN) population. Major differences are identified on the tables. The State covers the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries qualify for CN Medicaid coverage if their income is at or below 250 percent of the federal poverty level. Beneficiaries in this group pay a monthly premium equal to five percent of income except premiums under $10 are not collected. Any identified copayment requirements are applicable to beneficiaries age 18 and older in accordance with federal regulations. The copayment amount for x-ray services is also applicable to such services rendered in a clinic, physician office or outpatient hospital setting and may be collected in addition to a copayment required for other services provided.

Rhode Island: This State has an approved Section 1115 Global Waiver from CMS, the unique provisions of which capped federal Medicaid contributions at a predetermined level in exchange for State flexibility to redesign its public health care program. Only Disproportionate Share Hospital (DSH) payments and payments to Local Education Agencies (LEAs) are excluded. The waiver permitted the State to extend Medicaid eligibility to a number of previously uninsured individuals in its Rhode Island RIte Care and RIte Share programs, each with several components for different groups at different income levels. The optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 is included as well. All Medicaid-funded services on the continuum of care are now organized, financed and delivered under the authority of the Global Waiver. The tables reflect that Home and Community-Based Services (HCBS) Waivers are not covered. This does not mean that such services are not offered by the State, only that they are no longer covered through Section 1915(c) waivers and are now included under the Global Waiver. Beneficiaries are required to pay income-based monthly premiums and some services require copayments. Services are provided by managed care organizations. Only policies related to those services available to all adult populations or reimbursed directly by the State are reflected on the tables. Services in Rural Health Clinics are indicated as non-covered because the State has no such clinics.

South Carolina: This State has included the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 in its program since 1998. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level. Qualifying beneficiaries receive services through contracted managed care organizations, most of which offer additional services and do not charge copayments. Any identified copayment requirements are applicable to beneficiaries age 19 and older.

South Dakota: This State has added the optional Medicaid buy-in group of working adults with disabilities permissible through the Balanced Budget Act of 1997. These beneficiaries are eligible for Medicaid coverage and receive full benefits if they are working, their earned income is at or below 250 percent of the federal poverty level and they meet other financial eligibility criteria. There is no premium requirement and the group is subject to the same copayment requirements as other Medicaid beneficiaries.

Tennessee: This State has an approved Section 1115 waiver from CMS under which it serves two distinct populations under its TennCare program. TennCare Medicaid, identified on the tables as “A,” provides a comprehensive package of covered services with some limitations for adults and nominal copayment requirements for prescription drugs. The tables reflect that Home and Community-Based Services (HCBS) Waivers are not covered. This does not mean that such services are not offered by the State, only that they are no longer covered through Section 1915(c) waivers and have been folded into the Section 1115 waiver for TennCare Medicaid. TennCare Standard, identified on the tables as “B,” provides a similar package of services with the exception of nursing facility care for certain adults and children who do not meet eligibility criteria for TennCare Medicaid  and do not have access to employer-sponsored coverage or are uninsurable. Certain adults in TennCare Standard may be eligible for HCBS. Cost sharing requirements in TennCare Standard vary according to income level. TennCare Standard enrollees who are children with income at or above 100 percent of the federal poverty level (FPL) have cost sharing obligations; those with income above 100 percent but below 200 percent of the FPL (identified as B1) have lower copayment obligations than enrollees with income at or above 200 percent of the FPL (identified as B2). TennCare Standard adults who are not receiving HCBS have the same copayment requirements for prescription drugs as TennCare Medicaid adults. All TennCare services, including long-term care for the elderly and disabled but excluding long-term care for persons with mental retardation, are provided through managed care contractors (MCCs): managed care organizations, a dental benefits manager (for children) and a pharmacy benefits manager. MCCs have broad discretion relative to the types of providers they use as long as the providers deliver services within the scope of their licensure and have been appropriately credentialed by the MCC. Within contractual parameters, the MCCs establish their own prior authorization policies, reimbursement methodologies and payment rates. Accordingly, only limitations mandated by the State appear on the tables.

Texas: This State’s Medicaid population risk-based managed care program is called STAR – State of Texas Access Reform – and a companion program focused on service coordination and long-term care services for the elderly and disabled is called STAR+PLUS. The State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group are required to pay an income-based monthly premium up to a maximum of $500 if their income is at or above 150 percent of the FPL.

Utah: This State has an approved Section 1115 waiver from CMS under which it provides three different packages of services for its Medicaid beneficiaries. Traditional Medicaid, identified on the tables as “A,” provides a comprehensive package of covered services for primarily children, pregnant women, and the aged, blind and disabled, with some limitations and nominal copayments where permitted under federal law. Included in this category is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage if their income is at or below 250 percent of the federal poverty level (FPL); they are required to pay monthly income-based premiums and copayments. Non-traditional Medicaid, identified on the tables as “B,” provides a smaller package of covered services for certain adults receiving or previously receiving cash assistance through the State’s Temporary Assistance for Needy Families (TANF) program, with some limitations and nominal copayments up to an annual maximum of $500. The Primary Care Network, identified on the tables as “C,” provides a very limited package of covered services for parents of Medicaid-eligible children and other adults with income below 150 percent of the FPL, requires a $50 enrollment fee and has higher copayment obligations with an annual maximum of $1,000. The State does not require copayments for any preventive services.

Vermont: This State has an approved Section 1115 waiver from CMS called the Global Commitment to Health. The Department of Vermont Health Access, as a managed care entity, administers the waiver and Vermont’s public health coverage programs, including Medicaid and Vermont Health Access Plan (VHAP). Medicaid and VHAP services are delivered on a fee for service (FFS) basis or through the State’s Primary Care Case Management model of managed care called Primary Care Plus (PC Plus); VHAP PC Plus has more generous coverage than VHAP FFS. The State’s Traditional Medicaid population, including low-income families and caretaker relatives and the aged, blind and disabled, as well as optional and expansion populations of pregnant women with income at or below 200 percent of the federal poverty level (FPL) and the working disabled, permitted through the Balanced Budget Act of 1997, with income at or below 250 percent of the FPL are identified on the tables as “A”. The VHAP population includes uninsured adults age 18 and older with income at or below 185 percent of the FPL and is identified on the tables as “B”. Copayments are required for certain services. Income-based premiums are required from populations. The tables reflect that Home and Community-Based Services (HCBS) Waivers are not covered. This does not mean that such services are not offered by the State, only that they are no longer covered through Section 1915(c) waivers. The State covers institutional and community-based long-term care services for the elderly and physically disabled adults age 18 and older who meet nursing facility level of care criteria under a second Section 1115 waiver called Choices for Care. Institutional and community-based long-term care services for all other groups formerly covered under the State’s HCBS waivers are provided under the Global Commitment to Health waiver. These groups include persons with traumatic brain injury, persons with mental illness or developmental disabilities, children and adults in need of personal care due to disabilities and persons who are medically fragile or technology dependent.

Virginia: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 80 percent of the federal poverty level. No premiums are required.

Washington: This State has an approved Section 1115 waiver from CMS under which it extends Medicaid eligibility to children in families with income above 100 percent of the federal poverty level (FPL) who meet specified eligibility criteria. The waiver provisions permit the State to impose income-based monthly premiums. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 220 percent of the FPL and an income-based monthly premium is paid.

West Virginia: This State has received approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005 in a program called Mountain Health Choices. The program has a Basic and an Enhanced plan as well as a Traditional Medicaid Plan. The Basic plan (identified on the tables as “A”) includes all state and federal mandatory services and the Enhanced plan (identified on the tables as “B”) offers additional services to members voluntarily signing a health care responsibility agreement. Some of those additional services include weight management, tobacco cessation programs, diabetes education and nutritional counseling and education. West Virginia still offers Traditional Medicaid benefits to some of its beneficiaries (identified on the tables as “C”). This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits under their plan of choice, if their income is at or below 250 percent of the FPL and an income-based monthly premium is paid.

Wisconsin: This State declined to verify the information in the tables for the 2010 point in time so it was verified to the extent possible through online sources available. This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extends Medicaid eligibility to families and caretaker relatives with net income up to 200 percent of the federal poverty level (FPL). Beneficiaries with income above 150 percent of the FPL pay an income-based monthly premium. This population receives full Medicaid benefits either directly or as a wrap-around for services included in an employer’s insurance package through the BadgerCare Plus Standard Plan. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the FPL. Beneficiaries in this group must also pay an income-based monthly premium if their income is above 150 percent of the FPL. A limited benefit package with higher copayment requirements called the BadgerCare Plus Benchmark Plan is available for children and pregnant women with income between 200 percent and 300 percent of the FPL. Under another Section 1115 Waiver the BadgerCare Plus Core Plan is available for childless adults with income at or below 200 percent of the FPL. The Core Plan has a much slimmer benefit package of basic health care services and copayments that are similar to the Standard Plan. The table only reflects characteristics applicable to the State’s full benefit package. Any identified copayment requirements are applicable to pregnant women if the service is unrelated to pregnancy.

Wyoming: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their unearned income is at or below 300 percent of federal SSI benefit rate, which is about 222 percent of the federal poverty level (FPL).

American Samoa: This territory does not determine Medicaid eligibility on a case-specific basis. Instead, a “presumed eligibility” determination is made based on the percentage of the population (not counting illegal aliens) living below the federal poverty level. The calculation is made annually and is currently 87.7 percent. That percentage is applied to the computable costs of providing services, and the territory receives 50 percent of that amount as federal Medicaid financial participation up to a specified ceiling established in law. (The 50 percent rate increased to 55 percent on July 1, 2011 in accordance with a provision in the Patient Protection and Affordable Care Act (ACA) of 2010.) The Deficit Reduction Act (DRA) of 2005 provided additional funds to the territory, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years have been and will be similarly calculated. Moreover, the ACA provides significant add-ons to the calculated Medicaid payment ceiling beginning July 2011 and through September 2019. The LBJ Tropical Medical Center is the primary provider of medical services in American Samoa. The territory does not provide some of the services generally offered in the states, such as EPSDT and family planning, as well as home health, care in a nursing facility and private duty nursing, and the services of chiropractors and occupational therapists are not covered because there are none available.

Guam: Like the other territories, Guam has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. (The 50 percent rate increased to 55 percent on July 1, 2011 in accordance with a provision in the Patient Protection and Affordable Care Act (ACA) of 2010.) The Deficit Reduction Act (DRA) of 2005 provided additional funds to the territory, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years have been and will be similarly calculated. Moreover, the ACA provides significant add-ons to the calculated Medicaid payment ceiling beginning July 2011 and through September 2019.

Northern Mariana Islands: The Commonwealth has a single government-controlled and operated hospital and health system that provides the majority of its citizens’ health care services. Like the other territories, the Commonwealth has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. (The 50 percent rate increased to 55 percent on July 1, 2011 in accordance with a provision in the Patient Protection and Affordable Care Act (ACA) of 2010.) The Deficit Reduction Act (DRA) of 2005 provided additional funds to the Commonwealth, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years have been and will be similarly calculated. Moreover, the ACA provides significant add-ons to the calculated Medicaid payment ceiling beginning July 2011 and through September 2019. The hospital and health system is paid on a charge basis using Medicare cost ceilings. This methodology is also used for nursing facility services provided off island. For any other services not available through the hospital and health system, providers are paid negotiated rates or the applicable rates paid by the off island Medicaid program.

Puerto Rico: The Commonwealth of Puerto Rico Department of Health, as the single state agency, manages the Medicaid program. The population in Puerto Rico eligible for Medicaid receives health care services under a program called MiSalud (Spanish for My Health). All health care within the MiSalud program is provided through two contracted physical health managed care organizations (MCOs) and a single behavioral health organization (BHO). Depending on the particular region in which a Medicaid beneficiary resides, the MiSalud program assigns the beneficiary to one of the two physical health MCOs and to the BHO. The MCOs and BHO are required contractually to coordinate services between themselves and two pharmacy benefit managers. Like the other territories, Puerto Rico has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. (The 50 percent rate increased to 55 percent on July 1, 2011 in accordance with a provision in the Patient Protection and Affordable Care Act (ACA) of 2010.) The Deficit Reduction Act (DRA) of 2005 provided additional funds to Puerto Rico, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years have been and will be similarly calculated. Moreover, the ACA provides significant add-ons to the calculated Medicaid payment ceiling beginning July 2011 and through September 2019. The Commonwealth provides but does not claim federal Medicaid matching dollars for some services. Accordingly, although some services are not indicated as a covered benefit on the tables because they are not included in the State Plan, such as Home Health Services, Hospice Care, Medical Equipment and Supplies and Nursing Facility Services, the Commonwealth makes the services available to MiSalud beneficiaries on an exception basis.

Virgin Islands: Like the other territories, the US Virgin Islands has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. (The 50 percent rate increased to 55 percent on July 1, 2011 in accordance with a provision in the Patient Protection and Affordable Care Act (ACA) of 2010.) The Deficit Reduction Act (DRA) of 2005 provided additional funds to the Virgin Islands, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years have been and will be similarly calculated. Moreover, the ACA provides significant add-ons to the calculated Medicaid payment ceiling beginning July 2011 and through September 2019.