Trends in State Medicaid Programs: Looking Back and Looking Ahead
Introduction
To be eligible for ARRA funds, states could not restrict eligibility or tighten enrollment procedures in Medicaid or CHIP.
Vic Miller, Impact of the Medicaid Fiscal Relief Provisions in the American Recovery and Reinvestment Act (ARRA) (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2011), https://www.kff.org/medicaid/issue-brief/impact-of-the-medicaid-fiscal-relief-provisions/.
Section 1: Medicaid Spending and Enrollment Trends
Spending growth rates during SFYs 2011 through 2013 were affected by the end of the ARRA-enhanced matching rate. States shifted spending from SFY 2012 to SFY 2011 in order to take advantage of the higher match rate (which ended June 30, 2011.) In addition to this, states increased their cost containment efforts in response to the expiration of the enhanced match rates (which resulted in increased state costs.)
A total of 29 states were implementing the ACA Medicaid expansion in FY 2015, up from 26 states in the previous year (FY 2015 additions include: New Hampshire, Pennsylvania and Indiana). Alaska and Montana expanded in SFY 2016.
Section 2: Eligibility and Application/Renewals
Since the survey, Louisiana’s governor enacted an executive order to adopt the Medicaid expansion. Plans are to implement the Medicaid expansion in Louisiana beginning July 2016.
With new coverage available through the Marketplace, seven states (California, Iowa, Massachusetts, New Mexico, New York, Rhode Island and Vermont) eliminated Medicaid coverage in their waivers for adults with incomes over 138 percent FPL in SFY 2014. The following year, Connecticut reduce parent eligibility from 200 percent FPL to 155 percent FPL; Minnesota and New York shifted some populations to new Basic Health Plan programs as well. Additionally, some non-expansion states (Indiana, Oklahoma, Wisconsin and Maine) that had limited benefit coverage waivers also reduced eligibility down to 100 percent FPL.
CHIPRA also provided an opportunity for states to earn performance bonuses for enrolling children already eligible but not enrolled; in order to qualify, states had to meet specific enrollment targets and adopt certain enrollment/renewal simplifications.
Simplifications to the application and renewal process were further spurred by the availability of enhanced match for states made available under the ACA. Specifically, matching rates for new eligibility and enrollment systems was increased from 50 percent to 90 percent; the matching rate for maintenance and operations was increased from 50 percent to 75 percent. This rule was originally in effect through December 2015 but was recently made permanent.
Under the ARRA MOE, CMS determined that the following actions would be considered violations of the MOE requirements:
- Increasing stringency in institutional level of care (LOC) determination processes that results in individuals losing actual or potential eligibility for Medicaid pursuant to institutional eligibility rules or in the special eligibility group for HCBS waiver participants under 42 CFR 435.217;
- Adjusting cost neutrality calculations for section 1915(c) waivers from the aggregate to the individual, resulting in individuals being dropped from waiver coverage or hindered from moving out of an institutional setting;
- Reducing occupied waiver capacity for section 1915(c) HCBS waivers, or reducing or eliminating section 1915(c) waiver slots that were funded by the legislature but unoccupied as of July 1, 2008.
These standards were maintained under the ACA MOE, but CMS also notified states that it would be possible to increase institutional LOC criteria without violating the MOE if an alternative eligibility pathway to Medicaid HCBS services was created for all individuals that would have previously been able to gain eligibility under the original LOC. CMS offered the following examples of how this could be done: utilize the Section 1915(i) HCBS State Plan Option to extend HCBS benefits to individuals who would have been eligible under former LOC levels; or, use Section 1115 demonstration waiver authority to offer different levels of care for receipt of HCBS and institutional services, ensuring that the available capacity for Medicaid eligibility remains unchanged. CMS also noted that HCBS waivers are time limited and that the ACA MOE requirement does not require a state to renew a waiver that is expiring. Thus, a state may discontinue an HCBS waiver when it expires or may request a renewal at the end of the approved waiver period, with modifications, without creating an MOE issue.
Section 3: Benefits, Pharmacy and Long Term Care
Steve Eiken, Kate Sredl, Brian Burwell and Paul Saucier, Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2013 (Truven Health Analytics, June 30, 2015), http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-termservices-and-supports/downloads/ltss-expenditures-fy2013.pdf.
In some earlier years, benefit expansions for autism-related services were counted as expansions (PA -2009, MI-2013, MO-2013 and WA-2013.) However, CMS released guidance in X date that clarified that states are required to cover these services under EPSDT. For this analysis and in recent years, such changes are not counted as expansions, but included in appendix tables as (nc.)
PACE is a capitated managed care benefit for the frail elderly provided by a not-for-profit or public entity that features a comprehensive medical and social service delivery system. It uses a multidisciplinary team approach in an adult day health center supplemented by in-home and referral services in accordance with participant’s needs. In recent years, the number of states reporting increasing the number served in the community through this option has increased.
MaryBeth Musumeci, Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2014), https://www.kff.org/report-section/key-themes-in-capitated-medicaid-mltss-introduction/.
Between SFYs 2010 and 2012, 20 states enacted restrictions on home and community-based services such as personal care services and home health often by imposing utilization controls (increasing prior authorization, reducing service hours, etc.)
Since the most recent survey, Florida has terminated their 1915(i) as of December 2015. https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/FL/FL-15-012.pdf Original report did not include MI, which had a 1915(i) approved in 2013 for autism-related services. https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/MI/MI-12-015-Ltr.pdf
The Kaiser Family Foundation State Health Facts. Data Source: M. O'Malley Watts, E.L. Reaves, and M. Musumeci, Medicaid Balancing Incentive Program: A Survey of Participating States, Kaiser Commission on Medicaid and the Uninsured, June 2015; Medicaid.gov, Balancing Incentive Program. https://www.kff.org/medicaid/state-indicator/balancing-incentive-program/ Accessed June 6, 2016.
As of March 2016, 2 of the 4 states planning to adopt CFC (Connecticut and Washington) had SPAs approved.
The Kaiser Family Foundation State Health Facts. Data Source: Sylvia M. Burwell, Report to Congress Community First Choice: Final Report to Congress As Required by the Patient Protection and Affordable Care Act of 2010 (P.L. 111–148), U.S. Department of Health and Human Services, December 2015; Data from the Centers for Medicare and Medicaid Services and state websites compiled by KFF staff. https://www.kff.org/medicaid/state-indicator/section-1915k-community-first-choice-state-plan-option/ Accessed June 6, 2016.
Section 4: Provider Rates and Taxes
The ACA primary increase changes are not reflected in this data as they were required changes; physician rate increases reflected here only include changes to rates other than those required under this part of the ACA.
Medicaid Financing Issues: Provider Taxes (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, May 2011), https://www.kff.org/medicaid/fact-sheet/medicaid-financing-issues-provider-taxes/.
The seven states that reported plans at the time of the survey to use provider taxes or fees to fund all or part of the state costs for the ACA Medicaid expansion were Arizona, California, Colorado, Indiana, Kentucky, Nevada and Ohio. Plans are subject to change.
Medicaid Financing Issues: Provider Taxes (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, May 2011), https://www.kff.org/medicaid/fact-sheet/medicaid-financing-issues-provider-taxes/.
Medicaid Financing Issues: Provider Taxes (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, May 2011), https://www.kff.org/medicaid/fact-sheet/medicaid-financing-issues-provider-taxes/.
States and Medicaid Provider Taxes or Fees (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2016), https://www.kff.org/medicaid/fact-sheet/states-and-medicaid-provider-taxes-or-fees/.
Section 5: Managed Care and Delivery System Reform
Some of these states have small carve-outs for certain drugs or drug classes (e.g., HIV/AIDS drugs, medications for hepatitis C, mental health drugs, etc.)
Appendix
Laura Snyder, Robin Rudowitz, Eileen Ellis and Dennis Roberts, Medicaid Enrollment: June 2013 Data Snapshot (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 29, 2014), https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-june-2013-data-snapshot/.
