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A Look at Section 1115 Medicaid Demonstration Waivers Under the ACA: A Focus on Childless Adults

Executive Summary
  1. In addition, Connecticut provides coverage for childless adults through the ACA’s 2010 state plan option to expand coverage to childless adults up to 133% FPL prior to January 2014.

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Introduction
  1. Samantha Artiga. An Overview of Recent Section 1115 Medicaid Demonstration Waiver Activity (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, May 2012), http://kff.org/medicaid/issue-brief/an-overview-of-recent-section-1115-medicaid/.

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  2. Samantha Artiga and Cindy Mann. New Directions for Medicaid Section 1115 Waivers: Policy Implications of Recent Waiver Activity (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, March 2005), http://kff.org/medicaid/issue-brief/new-directions-for-medicaid-section-1115-waivers/.

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Issue Brief
  1. Cindy Mann. The New Medicaid and CHIP Waiver Initiatives (Kaiser Commission on Medicaid and the Uninsured, February 2002), http://www.kff.org/medicaid/report/the-new-medicaid-and-chip-waiver-initiatives/.

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  2. Samantha Artiga and Cindy Mann. New Directions for Medicaid Section 1115 Waivers: Policy Implications of Recent Waiver Activity (Kaiser Commission on Medicaid and the Uninsured, 2005), http://www.kff.org/medicaid/issue-brief/new-directions-for-medicaid-section-1115-waivers/.

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  3. Maine’s waiver was retro-active to October 2001.

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  4. Mann (2002) and Teresa Coughlin, et al, “An Early Look at Ten State HIFA Medicaid Waivers,” Health Affairs. 25:2 (April 2006), doi: 10.1377 /hlthaff.25.w204.

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  5. All HIFA waivers are required to include at least a feasibility study of premium assistance.

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  6. Laura Snyder and Robin Rudowitz. Medicaid Enrollment: June 2012 Data Snapshot (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, August 2013), http://www.kff.org/medicaid/issue-brief/medicaid-enrollment-june-2012-data-snapshot/.

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  7. State Medicaid Decisions as of September 30, 2013. Centers for Medicare & Medicaid Services (CMS). State Medicaid and CHIP Income Eligibility Standards Effective January 1, 2014 (September 30, 2013), http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Medicaid-and-CHIP-Eligibility-Levels/medicaid-chip-eligibility-levels.html.

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  8. A few states have county specific waiver coverage for childless adults including Cook County, Illinois; Cayahoga County, Ohio; and St. Louis, Missouri.

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  9. Washington, DC uses SPA and waiver for its childless adult coverage expansion.

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  10. Waivers will be required to implement both the proposed expansion passed by the Michigan legislature and Pennsylvania governor’s proposal.

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  11. CMS. 2014 Healthy Indiana Plan Extension Approval Letter (September 3, 2013), http://www.in.gov/fssa/hip/2429.htm.

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  12. CMS. “SoonerCare” Program Extension Approval Letter (September 3, 2013), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ok/ok-soonercare-ca.pdf.

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  13. Wisconsin Department of Health Services. BadgerCare+ Demonstration Project Waiver (August 15, 2013), http://www.dhs.wisconsin.gov/badgercareplus/waivers.htm.

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  14. Vernon Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz, and Laura Snyder. Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014 (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, October 2013), http://kff.org/medicaid/report/medicaid-in-a-historic-time-of-transformation-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2013-and-2014.

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  15. CMS. Frequently Asked Questions on Exchanges, Market Reforms and Medicaid (December 10, 2012), http://www.cms.gov/CCIIO/Resources/Files/Downloads/exchanges-faqs-12-10-2012.pdf.

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  16. BadgerCare+ Demonstration Project Waiver (August 15, 2013).

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  17. CMS. Affordable Care Act: State Resources FAQ (April 25, 2013), http://medicaid.gov/State-Resource-Center/FAQ-Medicaid-and-CHIP-Affordable-Care-Act-ACA-Implementation/Downloads/Affordable-Care-Act_-Newest-Version.pdf.

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  18. 42 C.F.R. § 1015, 78 Fed. Reg. 42160-42322 (July 15, 2013), https://www.federalregister.gov/articles/2013/07/15/2013-16271/essential-health-benefits-in-alternative-benefit-plans-eligibility-notices-fair-hearing-and-appeal; HHS, Medicaid and the Affordable Care Act: Premium Assistance (March 2013), http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/FAQ-03-29-13-PremiumAssistance.pdf.

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  19. Note that Iowa’s premium assistance application is for 100-133% FPL while Arkansas’ waiver is for all newly eligible adults (Iowa is proposing to cover newly eligible (and existing) adults under 100% FPL through Medicaid managed care through a separate waiver application).

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  20. Letter from Marilyn Tavenner, Dep’t of Health & Human Servs., to Andy Allison, Ark. Dep’t of Human Servs. (Sept. 27, 2013), http://posting.arktimes.com/media/pdf/arkansassignedapprovalltr.pdf.

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  21. MaryBeth Musumeci. Medicaid Expansion Through Premium Assistance: Arkansas and Iowa’s Section 1115 Demonstration Waiver Applications Compared (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, September, 2013),  http://www.kff.org/health-reform/fact-sheet/medicaid-expansion-through-premium-assistance-arkansas-and-iowas-section-1115-demonstration-waiver-applications-compared/.

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  22. Office of Governor Tom Corbett. Healthy Pennsylvania: Reforming Medicaid and Health Pennsylvania (September 17, 2013),  http://www.portal.state.pa.us/portal/server.pt?open=514&objID=1598151&parentname=ObjMgr&parentid=2&mode=2.

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  23. MaryBeth Musumeci. Medicaid Expansion Through Marketplace Premium Assistance  (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, September 2013), http://www.kff.org/medicaid/fact-sheet/medicaid-expansion-through-marketplace-premium-assistance/.

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  24. Joan Alker. Premium Assistance in Medicaid and CHIP: An Overview of Current Options and Implications of the Affordable Care Act (Kaiser Family Foundation, March 2013), http://www.kff.org/medicaid/issue-brief/premium-assistance-in-medicaid-and-chip-an-overview-of-current-options-and-implications-of-the-affordable-care-act/.

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  25. CMS. Questions and Answers: Medicaid and the Affordable Care Act (February 2013), http://medicaid.gov/State-Resource-Center/FAQ-Medicaid-and-CHIP-Affordable-Care-Act-ACA-Implementation/Downloads/ACA-FAQ-BHP.pdf.

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  26. Robin Rudowitz. Financing Medicaid Coverage Under Health Reform: What is in the Law and the New FMAP Rules (Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, May 2013), http://www.kff.org/health-reform/issue-brief/financing-medicaid-coverage-under-health-reform-the-role-of-the-federal-government-and-states/.

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  27. Office of Governor Tom Corbett (September 17, 2013).

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  28. Act No. 107, Public Acts of 2013.  Approved by the Governor, September 16, 2013 http://www.legislature.mi.gov/(S(a1hxol55sxpa3i453ukfwq55))/mileg.aspx?page=getObject&objectName=2013-HB-4714.

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  29. Federal Register Vol. 78, No. 135, July 15, 2013, pp. 42307-42310.

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  30. CMS. State Health Official/State Medicaid Director Letter:  Facilitating Medicaid and CHIP Enrollment and Renewal in 2014 (May 17, 2013), http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf.

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  31. Targeted Enrollment Strategies Approved by CMS as of October 1, 2103.  http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Targeted-Enrollment-Strategies/targeted-enrollment-strategies.html.

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Appendices
  1. There are additional Medicaid waiver authorities outside of Section 1115. The Affordable Care Act (ACA) created a new Center for Medicare and Medicaid Innovation (CMMI) which is provided waiver authority under Section 1115A to test, evaluate, and expand different service delivery and payment methodology demonstrations to foster patient-centered care, improve quality, and slow cost growth in Medicare, Medicaid, and CHIP. Further, Medicaid waivers may be authorized under Section 1915(b) to permit states to enroll most Medicaid beneficiaries in mandatory managed care and under Section 1915(c) to provide home and community-based services to people who would otherwise need institutional care. In addition, Section 1916(f) provides authority for the Secretary to approve higher cost sharing than otherwise allowed if a demonstration meets specified requirements.

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  2. U.S. Government Accountability Office. Medicaid Demonstration Waivers: Approval Process Raises Cost Concerns and Lacks Transparency (GAO-13-384) (June 2013), http://www.gao.gov/assets/660/655483.pdf.

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  3. CMS. Improved Review and Approval Process for Section 1115 Medicaid Demonstration Projects (February 22, 2012), http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4284. The regulations do not apply to amendments to existing Section 115 waivers or Section 1915 waivers.

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