A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020
Executive Summary
Centers for Medicare and Medicaid Services, National Health Expenditure Projections 2018 – 2027 (Washington, DC: Centers for Medicare and Medicaid Services, February 2019), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html.
Introduction
Centers for Medicare and Medicaid Services, National Health Expenditure Projections 2018 – 2027 (Washington, DC: Centers for Medicare and Medicaid Services, February 2019), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html.
Brian Sigritz, Summaries of FY 2020 Budgets (Washington, DC: NASBO, September 7, 2019) http://budgetblog.nasbo.org/budgetblogs/blogs/brian-sigritz/2019/09/06/summaries-of-fy2020-budgets.
National Conference of State Legislatures, FY 2020 State Budget Status (Washington, DC: NCSL, July 26, 2019), http://www.ncsl.org/research/fiscal-policy/fy-2020-state-budget-status.aspx.
National Association of State Budget Officers, Most States Close Out Fiscal 2019 with Revenue Growth, (National Association of State Budget Officers Budget Blog, September 2019), http://budgetblog.nasbo.org/budgetblogs/blogs/brian-sigritz/2019/07/17/most-states-close-out-fiscal-2019-with-revenue-gro.
Kaiser Family Foundation, 50-State Medicaid Budget Survey Archives (Washington, DC: Kaiser Family Foundation, October 2019), https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.
Maryland submitted a completed survey was unable to participate in a follow-up interview.
State fiscal years begin on July 1 except for these states: NY on April 1; TX on September 1; AL, MI and DC on October 1.
Eligibility and Premiums
Larisa Antonisse and Robin Rudowitz, An Overview of State Approaches to Adopting the Medicaid Expansion (Washington, DC: Kaiser Family Foundation, February 27, 2019), https://www.kff.org/medicaid/issue-brief/an-overview-of-state-approaches-to-adopting-the-medicaid-expansion/.
MaryBeth Musumeci, Robin Rudowitz, and Cornelia Hall, From Ballot Initiative to Waivers: What is the Status of Medicaid Expansion in Utah? (Washington, DC: Kaiser Family Foundation, September 23, 2019), https://www.kff.org/medicaid/issue-brief/from-ballot-initiative-to-waivers-what-is-the-status-of-medicaid-expansion-in-utah/.
Utah submitted to CMS its “Per Capita Cap” proposal for a new waiver that would continue a number of provisions already approved as well as a request for the enhanced match for partial expansion and a limit on enhanced federal funding. CMS issued a general statement in late July 2019 and a letter to the state in August 2019 confirming that they would not authorize the enhanced federal match rate for any expansion group smaller than the entire adult expansion group up to 138% FPL.
Centers for Medicare and Medicaid Services, Letter to Utah Governor Herbert from CMS Administrator, Seema Verma (August 16, 2019), medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/per-capita-cap/ut-per-capita-cap-correspondence-ltr-20190816.pdf.
The Governor said that the state plans to resubmit the application with additional information. CMS, however, specified that even a revised application would not be approved as it could not demonstrate compliance with the deficit neutrality guardrail.
Delaware and Hawaii had retroactive coverage waivers that pre-dated the ACA and may have been associated with achieving the budgetary savings necessary to expand coverage before federal law authorized the use of Medicaid funds for childless adults.
Not referenced in this bullet, in FY 2019, Connecticut increased the income limit from 155% FPL to 160% FPL for parent/caretakers.
Rachel Garfield, Robin Rudowitz, Kendal Orgera, and Anthony Damico, Understanding the Intersection of Medicaid and Work: What Does the Data Say? (Washington, DC: Kaiser Family Foundation, August 8, 2019), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-what-does-the-data-say/.
Rachel Garfield, Robin Rudowitz, Kendal Orgera, and Anthony Damico, Understanding the Intersection of Medicaid and Work: What Does the Data Say? (Washington, DC: Kaiser Family Foundation, August 8, 2019), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-what-does-the-data-say/.
Rachel Garfield, Robin Rudowitz, and MaryBeth Musumeci, Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses (Washington, DC: Kaiser Family Foundation, June 27, 2018), https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/.
Wisconsin's Section 1115 waiver covers childless adults ages 19 to 64 with income up to 100% FPL, without ACA enhanced matching funds. The state has an approved work and reporting requirement waiver for this population. The state plans to implement this provision as soon as CMS approves their implementation plan and when funding is made available for work supports.
In a letter dated September 25, 2019 from the Virginia Secretary of Health and Human Resources to the CMS Administrator, the state indicates it would be unable to move forward with implementation of the work and community engagement requirements without full federal funding for employment supports (requested in its pending Section 1115 waiver application).
MaryBeth Musumeci and Chelsea Rice, Ask KFF: Marybeth Musumeci Answers 3 Questions on Kentucky and Arkansas Medicaid Work and Reporting Requirement Cases, (Washington, DC: Kaiser Family Foundation, April 2, 2019), https://www.kff.org/medicaid/issue-brief/ask-kff-marybeth-musumeci-answers-3-questions-on-kentucky-arkansas-medicaid-work-and-reporting-requirement-cases/
Robin Rudowitz, MaryBeth Musumeci, and Cornelia Hall, February State Data for Medicaid Work Requirements in Arkansas (Washington, DC: Kaiser Family Foundation, March 25, 2019), https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/
Previously, in July 2019, New Hampshire enacted legislation that allowed for the suspension of the work requirement’s implementation up to but not after July 1, 2021, and suspended the work requirement through September 30, 2019.
Government Accountability Office, Actions Needed to Address Weaknesses in Oversight of Costs to Administer Work Requirements (Washington, DC: U.S. Government Accountability Office, October 10, 2019), https://www.gao.gov/products/GAO-20-149
Tricia Brooks, Lauren Roygardner, and Samantha Artiga, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey (Washington, DC: Kaiser Family Foundation, March 2019), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2019-findings-from-a-50-state-survey/view/footnotes/
Louisiana did not report data in the 2019 Kaiser Family Foundation Medicaid Budget Survey so data from the 2017 survey was used for this analysis.
Alexandra Gates, Samantha Artiga, and Robin Rudowitz, Health Coverage and Care for the Adult Criminal Justice Population, (Washington, DC: Kaiser Family Foundation, September 5, 2014), https://www.kff.org/uninsured/issue-brief/health-coverage-and-care-for-the-adult-criminal-justice-involved-population/
Two states did not report: MD, SD
MaryBeth Musumeci, and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act (Washington, DC, Kaiser Family Foundation, October 2018) https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/
Delivery Systems
Connecticut does not have capitated managed care arrangements, but does carry out many managed care functions, including ASO arrangements, payment incentives based on performance, intensive care management, community workers, educators, and linkages with primary care practices.
Vermont runs a public, non-risk bearing prepaid health plan delivery model under its Section 1115 Global Commitment to Health waiver. In FY 2019, Vermont ended its PCCM program (operated within the waiver) but continues to promote increased participation in the Vermont All-Payer Accountable Care Organization (ACO) model. In CY 2019, approximately 47% of Medicaid enrollees receive services under the ACO model.
In addition to furnishing basic PCCM services, PCCM entities also provide other services such as intensive case management, provider contracting or oversight, enrollee outreach, and/or performance measurement and quality improvement. 42 CFR §438.2.
South Carolina uses PCCM authority to provide care management services to medically complex children but is not counted as a PCCM program for purposes of this report.
Centers for Medicare and Medicaid Services, Medicaid & CHIP Monthly Application, Eligibility Determinations, and Enrollment Reports, (Washington, DC: Centers for Medicare and Medicaid Services, June 2019), https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/monthly-reports/index.html.
Maryland reported the MCO penetration rate for all beneficiaries but did not report penetration rates for the individual eligibility categories so penetration rates that the state reported in the 2018 survey were used for this analysis.
Arkansas began an MCO program in FY 2019, but it does not enroll expansion adults. The five Medicaid expansion states without risk-based managed care were Alaska, Connecticut, Maine, Montana, and Vermont.
Massachusetts reported covering 48% of expansion adults in MCOs and Arkansas began an MCO program in FY 2019, but it does not enroll expansion adults. Utah implemented a partial expansion to 100% in FY 2019 (without ACA enhanced matching funds) and reported covering approximately 13% of this population in MCOs, but is not included as a ACA Medicaid expansion state here.
In April 2016, CMS issued a final rule on managed care in Medicaid and CHIP that provided a framework of plan standards and requirements designed to improve the quality, performance, and accountability of these programs. The current administration proposed changes to the final rule in November 2018, however, these have not yet been finalized.
New Mexico reported eliminating the use of quality metrics in its auto-assignment algorithm in its MCO contracts effective December 31, 2018.
National Association of Medicaid Directors, Medicaid Value-Based Purchasing: What Is It & Why Does It Matter? (Washington, DC: National Association of Medicaid Directors, January 2017), http://medicaiddirectors.org/wp-content/uploads/2017/01/Snapshot-2-VBP-101_FINAL.pdf.
For more information on the State Innovation Models (SIM) initiative, see: https://innovation.cms.gov/initiatives/state-innovations/.
Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework, Fact Sheet; accessed at http://hcp-lan.org/workproducts/apm-factsheet.pdf. CMS launched the LAN in 2015 to encourage alignment across public and private sector payers by providing a forum for sharing best practices and developing common approaches to designing and monitoring of APMs, as well as by developing evidence on the impact of APMs.
CMCS Information Bulletin, Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates (Baltimore, MD: Centers for Medicare and Medicaid Services, June 30, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf.
DC does not require MLR remittances, but if an MCO’s MLR falls below 85%, they are required to study what has caused the MLR to fall below 85% and take corrective action. DC has discretion to require the MCO to pay a civil monetary penalty for failing to provide covered services, including failing to adhere to acceptable financial practices and standards for operating an MCO.
One of the 28 states reporting a PHP arrangement that is not included in Exhibit 12 is Alabama, which reported having a PHP for maternity care.
Samantha Artiga and Elizabeth Hinton, Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity (Washington, DC: Kaiser Family Foundation), https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
Centers for Medicare and Medicaid Services, CMS’ Accountable Health Communities Model selects 32 participants to serve as local “hubs”, (Baltimore, MD: Centers for Medicare and Medicaid Services, April 2017), https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-04-06.html.
Centers for Medicare and Medicaid Services, The Accountable Health Communities Health-Related Social Needs Screening Tool, https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf.
Centers for Medicare and Medicaid Services, Accountable Health Communities Model, https://innovation.cms.gov/initiatives/ahcm/ (accessed on September 9, 2019).
MD and MI did not report on “Provide enrollees with referrals to social services”; MD did not report on the “Screen enrollees for social needs”; MD did not report on “Partner with community-based organizations or social service providers”; MD did not report on “Employ community health works”; IA, MD, NY did not report on “Track the outcome of referrals to social services; MD, NY did not report on “Encourage or require providers to capture social determinants of health data using ICD-10 Z codes*”.
Healthcare professionals use “ICD-10” diagnosis and inpatient procedure codes to identify and document health conditions in a patient’s electronic health record and for billing purposes. The ICD-10 also includes an expanded set of codes reflecting social characteristics in the form of “Z codes.” For example, Z59.9 is “problem related to housing and economic circumstances unspecified.”
State of Michigan, Sample Medicaid Managed Care Contract, accessed October 10, 2019. https://www.michigan.gov/documents/contract_7696_7.pdf see page 65.
North Carolina Department of Health and Human Services, “NCCARE360”, accessed October 10, 2019. https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities/nccare360
Elizabeth Hinton, Samantha Artiga, MaryBeth Musumeci, and Robin Rudowitz, A First Look at North Carolina’s Section 1115 Medicaid Waiver’s Healthy Opportunities Pilots (Washington, DC: Kaiser Family Foundation, May 15, 2019), https://www.kff.org/medicaid/issue-brief/a-first-look-at-north-carolinas-section-1115-medicaid-waivers-healthy-opportunities-pilots/
Montana House Bill 599 (signed by Governor May 9, 2019), https://leg.mt.gov/bills/2019/billpdf/HB0599.pdf.
Agency for Healthcare Research and Quality, Pathways Community HUB Manual, (Rockville, MD: Agency for Healthcare Research and Quality, HHS, January 2016), https://innovations.ahrq.gov/sites/default/files/Guides/CommunityHubManual.pdf
Kaiser Family Foundation, How Connecting Justice-Involved Individuals to Medicaid Can Help Address the Opioid Epidemic (Washington, DC: Kaiser Family Foundation, June 2019), https://www.kff.org/medicaid/issue-brief/how-connecting-justice-involved-individuals-to-medicaid-can-help-address-the-opioid-epidemic/.
In this year’s survey, Georgia and Maryland did not report policies related to care coordination prior to release from incarceration in FFS or Medicaid managed care. Michigan and New Hampshire did not report policies related to care coordination prior to release in Medicaid Managed care.
National Committee on Quality Assurance, “Patient-Centered Medical Home Recognition,” Accessed October 10, 2019. http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx.
Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concepts (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), http://kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/.
Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concept (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), http://kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/.
Colorado Department of Health Care Policy and Financing, “Accountable Care Collaborative Phase II,” Accessed October, 10 2019. https://www.colorado.gov/pacific/hcpf/accphase2.
Alexandra Gates, Robin Rudowitz, and Jocelyn Guyer, An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers (Washington, DC, Kaiser Commission on Medicaid and the Uninsured, September 2014), https://www.kff.org/report-section/findings-from-the-field-medicaid-delivery-systems-and-access-to-care-in-four-states-in-year-three-of-the-aca-issue-brief/.
In this report, Oregon’s Coordinated Care Organization (CCO) program is counted as an MCO program, but not as an ACO program, consistent with its CMS designation and the state’s survey response. According to the state, “A coordinated care organization is a network of all types of health care providers (physical health care, addictions and mental health care and sometimes dental care providers) who have agreed to work together in their local communities to serve people who receive health care coverage under the Oregon Health Plan (Medicaid).” (Oregon Health Authority website accessed at: http://www.oregon.gov/oha/HPA/Pages/CCOs-Oregon.aspx.)
Connecticut Department of Social Services, “Person-Centered Medical Home Plus (PCMH+)” Accessed October 10, 2019. https://portal.ct.gov/dss/Health-and-Home-Care/PCMH-Plus.
Consumer Assessment of Healthcare Providers and Systems
Centers for Disease Control and Prevention, Pregnancy Mortality Surveillance System (Atlanta, GA: CDC, June, 2019), https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpmss.html.
Martin JA, Hamilton BE, Osterman MJK., Births in the United States, 2017 (Hyattsville, MD: Centers for Disease Control and Prevention, National Center for Health Statistics, August 2018), https://www.cdc.gov/nchs/data/databriefs/db318.pdf
Medicaid and CHIP Payment and Access Commission, Access in Brief: Pregnant Women and Medicaid, November 2018 Issue Brief; accessed at https://www.macpac.gov/wp-content/uploads/2018/11/Pregnant-Women-and-Medicaid.pdf.
CO, IN, LA, ME, MI, MO, NH, OH, TN, TX, WV
Also, Florida reported that its MCOs offered a number of value-added services for pregnant women including doula services and expanded dental benefits; Indiana reported that a new state “OB Navigator” program will identify women early in their pregnancies, especially Medicaid enrollees, and connect them to home visiting programs; and Pennsylvania reported plans to require its MCOs to coordinate with existing evidenced-base home visiting programs.
Benefits and Cost-Sharing
Amy Chen, Q&A on Pregnant Women’s Coverage Under Medicaid and the ACA, (Washington, DC: National Health Law Program, September 5, 2018) https://healthlaw.org/resource/qa-on-pregnant-womens-coverage-under-medicaid-and-the-aca/.
Illinois has an approved Section 1115 Waiver to cover evidence-based home visiting services under a pilot program, including postpartum home visits and child home visits to postpartum mothers who gave birth to a baby born with withdrawal symptoms. Implementation is planned for FY 2020.
Texas expanded coverage of telemedicine services to occupational therapy and speech-language pathology provided in a school-based setting in FY 2019.
Minnesota added coverage of telemedicine services provided by community health workers in FY 2020.
Centers for Medicare and Medicaid Services, Medicaid Opportunities in the Emergency Triage, Treat, and Transport (ET3) Model (Baltimore, MD: CMS, August 8, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib080819-3.pdf.
Centers for Medicare and Medicaid Services, State Guidance for Implementation of the Treatment for Infants with Neonatal Abstinence Syndrome in Residential Pediatric Recovery Centers Provisions of Section 1007 of Pub. L. 115-271, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Baltimore, MD: CMS, July 26, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib072619-1007.pdf.
Centers for Medicare and Medicaid Services, State Guidance for Implementation of the Treatment for Infants with Neonatal Abstinence Syndrome in Residential Pediatric Recovery Centers Provisions of Section 1007 of Pub. L. 115-271, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Baltimore, MD: CMS, July 26, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib072619-1007.pdf.
CMS, West Virginia State Plan Amendment #17-0004, https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/WV/WV-17-004.pdf.
In FY 2019 Nevada imposed prior authorization requirements for Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Magnetic Resonance Spectroscopy (MRS), and Positron Emission Tomography. (PET) scan services. In FY 2020 it eliminated the new prior authorization requirements because the administrative cost did not outweigh the savings.
Julia Paradise, Medicaid Moving Forward (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2015), http://kff.org/health-reform/issue-brief/medicaid-moving-forward/.
Samantha Artiga, Petry Ubri, and Julia Zur, The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings (Washington, DC: Kaiser Family Foundation, June 1, 2017), https://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings/.
Colorado General Assembly, Senate, Concerning Wholesale Importation of Prescription Pharmaceutical Products from Canada for Resale to Colorado Residents, and, In Connection Therewith, Making an Appropriation, SB 19-005, introduced January 4, 2019, https://leg.colorado.gov/bills/sb19-005.
Substance Abuse and Mental Health Services Administration (SAMHSA), 2016 National Survey on Drug Use and Health: Detailed Tables (Rockville, MD: SAMHSA, September 2017), https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf.
“Understanding the Epidemic,” Centers for Disease Control and Prevention, accessed on September 8, 2019, https://www.cdc.gov/drugoverdose/epidemic/index.html.
Holly Hedegaard, Arialdi M. Miniño, and Margaret Warner, Drug Overdose Deaths in the United States, 1999–2017, (Hyattsville, MD: Center for Disease Control and Prevention, National Center for Health Statistics, November 2018), https://www.cdc.gov/nchs/data/databriefs/db329-h.pdf.
Centers for Disease Control and Prevention, “Understanding the Epidemic,” accessed on September 8, 2019, https://www.cdc.gov/drugoverdose/epidemic/index.html.
Kaiser Family Foundation, Medicaid’s Role in Addressing the Opioid Epidemic (Washington, DC: Kaiser Family Foundation, June 3, 2019), https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/.
Centers for Medicare and Medicaid Services, New Service Delivery Opportunities for Individuals with a Substance Use Disorder (Baltimore, MD: CMS, July 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf.
Centers for Medicare and Medicaid Services, Strategies to Address the Opioid Epidemic (Baltimore, MD: CMS, November 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.
MaryBeth Musumeci and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/.
In 2016, the Centers for Disease Control and Prevention (CDC) published recommendations for prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guidelines address matters such as when to initiate or continue opioids, opioid dosage and duration, and mitigating patient risk factors. Many states have adopted the CDC guidelines or have developed their own opioid prescribing guidelines.
Prospective drug utilization review activities include screening prescription drug claims to identify potential problems related to opioid abuse and overdose risk (e.g., alerts regarding early refills, prescriptions in excess of drug quantity limitations, concurrent utilization of opioids and benzodiazepines) and includes hard and soft safety edits at the point-of-sale.
Step therapy prior authorization criteria involves requiring the use of another agent or therapy prior to the use of a specific opioid.
Retrospective drug utilization examines paid prescription drug claims to identify patterns of fraud, abuse, or misuse.
Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases that are valuable tools for addressing prescription drug diversion and abuse. Currently, except for Missouri, every state and the District of Columbia operates a PDMP.
Drug lock-in programs restrict beneficiaries to a single prescriber and/or pharmacy when utilization of medical or pharmacy services is identified as excessive or potentially fraudulent.
Centers for Medicaid and CHIP Services, State Guidance for Implementation of Medicaid Drug Utilization Review (DUR) provisions included in Section 1004 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (Baltimore, MD: Centers for Medicare and Medicaid Services, August 5, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib080519-1004.pdf.
Frequently Asked Questions: SUPPORT for Patients and Communities Act, Section 5042 – Medicaid PARTNERSHIP Act, https://www.medicaid.gov/federal-policy-guidance/downloads/faq051519.pdf.
Substance Abuse and Mental Health Services Administration, “Medication-Assisted Treatment (MAT),” (Substance Abuse and Mental Health Services Administration, last updated 02/07/2018), https://www.samhsa.gov/medication-assisted-treatment.
The Pew Charitable Trusts, Medication-Assisted Treatment Improves Outcomes for Patients With Opioid Use Disorder (Washington, DC: The Pew Charitable Trusts, November 2016), http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder.
Substance Abuse and Mental Health Services Administration, “Medication-Assisted Treatment (MAT),” Substance Abuse and Mental Health Services Administration, last updated 02/07/2018, https://www.samhsa.gov/medication-assisted-treatment.
Naltrexone does not carry abuse or diversion potential, and any provider licensed to prescribe medications can prescribe naltrexone. However, to prescribe or dispense buprenorphine, physicians must obtain a “waiver”. This process involves 1) registering with the Drug Enforcement Administration (DEA) to dispense controlled substances; 2) certifying intent to treat no more than 30 patients at one time in the first year; and 3) receipt of required training or certification. Physicians may apply to increase the allowable patient caseload, and if approved may treat up to 100 patients in their first year and up to 275 patients in subsequent years. Methadone may only be dispensed by opioid treatment programs certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Opioid treatment programs may also dispense buprenorphine.
Some states interviewed in this year’s survey expressed concerns that the SUPPORT Act requires coverage of non-rebatable drugs and are awaiting federal guidance on the topic.
Kaiser Family Foundation, Medicaid’s Role in Addressing the Opioid Epidemic (Washington, DC: Kaiser Family Foundation, June 3, 2019), https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/.
Substance Abuse and Mental Health Services Administration, “Naltrexone”, last updated 05/07/19, https://www.samhsa.gov/medication-assisted-treatment/treatment/naltrexone.
43 states include: 33 states reporting use of in lieu authority in FY 2019 and FY 2020 or just FY 2020 (see Table 9); 8 states with SUD waivers that did not report using in lieu of authority in FY 2020 (AK, CA, KS, MD, NM, PA, VT, WV); and 2 additional states not included in two cohorts above that plan to utilize the SPA option in 2020 (ID, SD).
81 FR 27497, available at: https://www.gpo.gov/fdsys/granule/FR-2016-05-06/2016-09581.
CMS, SMD #15-003, New Service Delivery Opportunities for Individuals with a Substance Use Disorder (July 27, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf.
CMS, SMD #17-003, Strategies to Address the Opioid Epidemic (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.
Kaiser Family Foundation, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State”, last updated October 9, 2019, https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/.
CMS, SMD #18-011, Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance (Nov. 13, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf.
MaryBeth Musumeci and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act (Washington, DC: Kaiser Family Foundation, October 5, 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/.
H.R. 6, § 1012; see also CMCS Informational Bulletin, State Guidance for the New Limited Exception to the IMD Exclusion for Certain Pregnant and Postpartum Women included in Section 1012 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. 115-271), entitled Help for Moms and Babies (July 26, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib072619-1012.pdf.
These states (NM, WV) may have discontinued use of Medicaid managed care "in lieu of" authority in FY 2020 due to approval/implementation of Section 1115 IMD SUD waivers.
As of October 2019, DC, IN, and VT have submitted Section 1115 IMD waivers for services for individuals with SMI or SED.
MD did not report.
Kaiser Family Foundation, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State”, last updated October 9, 2019, https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/.
MD did not report.
Long-Term Services and Supports
MaryBeth Musumeci, Priya Chidambaram, and Molly O'Malley Watts, Medicaid Home and Community-Based Services Enrollment and Spending (Washington, DC: Kaiser Family Foundation, April 4, 2019), https://www.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/.
22 of the 25 capitated MLTSS states report using rebalancing incentives in their managed care contracts. One additional state, Alabama, reports building rebalancing incentives in its managed FFS MLTSS contract.
Molly O’Malley Watts, MaryBeth Musumeci, and Petry Ubri, Medicaid Section 1115 Managed Long-Term Services and Supports Waivers: A Survey of Enrollment, Spending an Program Policies, (Washington, DC: Kaiser Family Foundation, January 2017), http://www.kff.org/medicaid/report/medicaid-section-1115-managed-long-term-services-and-supports-waivers-a-survey-of-enrollment-spending-and-program-policies/.
U.S. Senate Commission on Long-Term Care, Report to the Congress, (U.S. Senate Commission on Long-Term Care, September 2013), https://www.gpo.gov/fdsys/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf.
US Department of Health and Human Services, Long-Term Services and Supports: Direct Care Worker Demand Projections 2015-2030 (Health Resources and Services Administration Bureau of Health Workforce, US Department of Health and Human Services, March 2018), https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/hrsa-ltts-direct-care-worker-report.pdf.
MaryBeth Musumeci and Molly O’Malley Watts, Lessons Learned from Eight Years of Supporting Institutional to Community Transitions Through Medicaid’s Money Follows the Person Demonstration (Washington, DC: Kaiser Family Foundation, October 16, 2015), https://www.kff.org/medicaid/perspective/lessons-learned-from-eight-years-of-supporting-institutional-to-community-transitions-through-medicaids-money-follows-the-person-demonstration/.
Center for Medicaid and CHIP Services Informational Bulletin, Coverage of Housing-Related Activities and Services for Individuals with Disabilities (June 26, 2015) https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf.
Center for Medicaid and CHIP Services Informational Bulletin, Coverage of Housing-Related Activities and Services for Individuals with Disabilities (June 26, 2015) https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf.
Elizabeth Hinton, Samantha Artiga, Mary Beth Musumeci, and Robin Rabinowitz, A First Look at North Carolina’s Section 1115 Medicaid Waiver’s Healthy Opportunity Pilots (Kaiser Family Foundation, May 15, 2019 ) https://www.kff.org/report-section/a-first-look-at-north-carolinas-section-1115-medicaid-waivers-healthy-opportunities-pilots-issue-brief/.
Oregon is not included in this count. The state terminated its MFP program, effective June 30, 2015.
H. Stephen Kaye, Ph.D., Evidence for the Impact of the Money Follows the Person Program, Community Living Policy Center, Lurie Institute for Disability Policy, Brandeis University, July 2019) https://clpc.ucsf.edu/sites/clpc.ucsf.edu/files/reports/Evidence%20for%20the%20Impact%20of%20MFP_0.pdf
Most of these states are using current Section 1915(c) waivers that provide community transition services and environmental modifications for seniors, individuals with physical disabilities and/or individuals with I/DD , and some states offer housing coordinators or other search services to assist waiver beneficiaries.
Mathematica Policy Research, Money Follows the Person 2015 Annual Evaluation Report, (Submitted to U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services, May 11, 2017) https://www.medicaid.gov/medicaid/ltss/downloads/money-follows-the-person/mfp-2015-annual-report.pdf
After December 2019, with CMS approval, states will have four years in which to expend remaining MFP funds absent additional Federal action to reauthorize the program.
One MFP state (MD) did not report.
The Affordable Care Act (ACA) authorized the Secretary of Health and Human Services to implement the Financial Alignment Initiative to allow state-administered demonstration projects to improve the integration and coordination of services for individuals who are covered under both Medicare and Medicaid. This population, as a group, experiences high rates of hospitalization and use of LTSS and is, on average, a high need, high cost population. See: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.html..
Kaiser Commission on Medicaid and the Uninsured, Health Plan Enrollment in the Capitated Financial Alignment Demonstrations for Dual Eligible Beneficiaries (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2016), http://kff.org/medicaid/fact-sheet/health-plan-enrollment-in-the-capitated-financial-alignment-demonstrations-for-dual-eligible-beneficiaries/.
CMS, SMD #19-002, Three New Opportunities to Test Innovative Models of Integrated Care for Individual’s Dually Eligible for Medicaid and Medicare (April 24, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/smd19002.pdf.
CMS, SMD #19-002, Three New Opportunities to Test Innovative Models of Integrated Care for Individual’s Dually Eligible for Medicaid and Medicare (April 24, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/smd19002.pdf.
Edith G. Walsh, Financial Alignment Initiative Washington Health Home MFFS Demonstration: Third Evaluation Report (RTI International, Waltham MA for Centers for Medicare & Medicaid Services Center for Medicare & Medicaid Innovation, August 2019) https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/WAEvalReport3.pdf.
Ibid, CMS SMD #19-002, April 24, 2019.
Arizona, Hawaii, Idaho, Massachusetts, Minnesota, New Mexico, Pennsylvania, Tennessee, Texas, Virginia, Wisconsin (WI Partnership MCOs are required to contract with FIDE plans, not Family Partnership PHPs).
Dual Eligible Special Needs Plans (D-SNPs) enroll beneficiaries who are entitled to both Medicare and Medicaid and offer the opportunity to better coordinate benefits among Medicare and Medicaid. For more information see: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/DualEligibleSNP.html.
Fully Integrated Dual Eligible SNPs were created by Congress in Section 3205 of the Affordable Care Act to promote full integration and coordination of Medicaid and Medicare benefits for dual eligible beneficiaries by a single managed care organization. They must have a MIPPA compliant contract with a State Medicaid Agency that includes coverage of specified primary, acute and long-term care benefits and services under risk-based financing. For more information see: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/DualEligibleSNP.html#s3.
CMS, SMD # 18-012, Ten Opportunities to Better Serve Individuals Dually Eligible for Medicaid and Medicare (December 19, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/smd18012.pdf.
In one of the following HCBS waivers: Supportive Living Program, Persons with Disabilities, Persons with HIV or AIDS, Persons with Brain Injury, and Persons who are Elderly.
TennCare II Demonstration, Amendment 40, Draft for Public Review, August 5, 2019. https://www.tn.gov/content/dam/tn/tenncare/documents2/Amendment40.pdf.
Provider Rates and Taxes
Tennessee is the only state that didn’t indicate any provider rate increases in FY 2019; the state also did not report any rate cuts (although freezes count as a restriction in this survey). Because the Tennessee Medicaid program is 100% managed care, it is not clear how this affects rates to providers in managed care.
Historically, Medicaid reimbursement for hospitals and nursing homes was cost-based, automatically reflecting incurred cost increases. When rates for these providers are frozen, such annual increases do not occur; hence for this report, rate freezes are counted as restrictions.
New Hampshire was not able to report MCO rate changes for FY 2020 due to lack of a budget for FY 2020.
Some states also have premium or claims taxes that apply to managed care organizations and other insurers. Since this type of tax is not considered a provider tax by CMS, these taxes are not counted as provider taxes in this report.
California has had an MCO tax for several years. That tax expired on June 30, 2019, so the state is seeking a new one which will be retroactive to July 1, 2019.
The Deficit Reduction Act of 2005 modified section 1903(w)(7)(A) of the Social Security Act. This statute and the implementing regulations eliminated states’ ability to tax only Medicaid MCOs.
Challenges and Priorities in FY 2020 and Beyond Reported by Medicaid Directors and Conclusion
MaryBeth Musumeci, Explaining Texas v. U.S.: A Guide to the 5th Circuit Appeal in the Case Challenging the ACA (Washington, DC: Kaiser Family Foundation, June 3, 2019), https://www.kff.org/health-reform/issue-brief/explaining-texas-v-u-s-a-guide-to-the-5th-circuit-appeal-in-the-case-challenging-the-aca/.
Methods
Kaiser Family Foundation, 50-State Medicaid Budget Survey Archives, (Washington, DC: Kaiser Family Foundation, October 2019), https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.
State fiscal years begin July 1 except for these states: NY on April 1; TX on September 1; AL, MI and DC on October 1.
Maryland submitted a completed survey was unable to participate in a follow-up interview.