Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015
Introduction
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 Enrollment
Connecticut covered parents up to 201% FPL; childless adults with incomes above 138% FPL were not covered under Medicaid in the state.
Under the HIP waiver extension, parents will not be limited by enrollment caps or open enrollment periods, and will have the ability to enroll in HIP provided they make the required contributions. Enrollment for childless adults will continue to be capped; however, the cap was increased as part of the waiver renewal.
Family planning waivers and SPAs offer limited benefits while the breast and cervical cancer treatment program and the medically needy spend-down programs offer full Medicaid benefits but are limited to those with either a specific condition or after meeting spend-down requirements.
Louisiana is planning to shift those under 133% FPL from the Family Planning waiver to a SPA.
Indiana operated as a Section 209(b) state; under Section 209(b) of the Social Security Act, states develop their own disability determination methods for determining eligibility for aged, blind, and disabled groups. As part of this option, states must operate a spend-down program. Indiana switched to operate as a Section 1634 state, which relies on disability determinations by the Social Security Administration. As a Section 1634 state, Indiana could no longer operate a spend-down program.
New Hampshire had also previously implemented 12 month continuous eligibility for adults through an 1115 waiver.
Center for Medicaid and CHIP Services, CMCS Informational Bulletin: Implementation of Hospital Presumptive Eligibility, (Centers for Medicare and Medicaid Services, January 24, 2014.) http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-01-24-2014.pdf.
- Positive changes from the beneficiary’s perspective that were counted in this report are denoted with (+). Negative changes from the beneficiary’s perspective that were counted in this report are denoted with (-). Several states made reductions to Medicaid eligibility pathways in response to either the availability of coverage through the Marketplaces and/or through the Medicaid expansion; these changes were denoted as (#) since most affected beneficiaries will have access to coverage through an alternative pathway. Other changes to Medicaid eligibility that are not likely to affect beneficiaries but were reported by states are denoted with (nc).
- This is in lieu of the “217-like option” which had been approved by CMS as part of the state’s comprehensive waiver, but proved challenging to implement.
Delivery System Reforms
Mississippi is included in the counts for states operating MCOs; however, their risk-based managed care program does not cover inpatient hospital services. ID’s MMCP program, which is secondary to Medicare, has been re-categorized by CMS from a PAHP to an MCO by CMS but is not counted here as such. CA has a small PCCM program operating in LA county for those with HIV.
Vermont noted that under the state’s Section 1115 Global Commitment waiver which includes a global cap, the state’s PCCM program operates as if it were a public sector risk-bearing MCO. The SIM grant is part of the state’s efforts to move eventually to a single-payer system. The state passed legislation in 2011 to implement a single-payer health care system after additional waiver authority through the ACA becomes available.
Not counted here is Massachusetts; this state also adopted policies (expanding the availability of other options) which resulted in decreased enrollment in PCCM programs; however, this was not the intent of the policy changes.
Hawaii auto assigns all new members to a health plan and then offers them a choice.
Kaiser Commission on Medicaid and the Uninsured, Decoding Medicaid Care Delivery and Financing Models: A Glossary of Widely Used Terms, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured,) May 2012. http://www.kff.org/medicaid/8313.cfm.
States can submit more than one SPA targeting different populations and there are no deadlines related to this option. The enhanced funding is available for the first 8 quarters of each SPA.
Julia Paradise, Health Homes for Medicaid Beneficiaries with Chronic Conditions, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured,) August 2012. http://www.kff.org/medicaid/8340.cfm.
Kaiser Commission on Medicaid and the Uninsured, Decoding Medicaid Care Delivery and Financing Models: A Glossary of Widely Used Terms, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured,) May 2012. http://www.kff.org/medicaid/8313.cfm.
Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey Cost and Use file, 2009.
Katherine Young, Rachel Garfield, MaryBeth Musumeci, Lisa Clemans-Cope, and Emily Lawton. Medicaid’s Role for Dual Eligible Beneficiaries, (Kaiser Commission on Medicaid and the Uninsured,) August 2013. https://www.kff.org/wp-content/uploads/2013/08/7846-04-medicaids-role-for-dual-eligible-beneficiaries.pdf.
Ten of the states planning to implement a financial alignment demonstration in FY 2015 had MOUs approved with CMS; Connecticut, Rhode Island and Oklahoma had proposals pending at CMS.
Musumeci, MaryBeth, Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS, (Kaiser Family Foundation, July 2014.) https://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-compared/.
State Health Facts, Distribution of Medicaid Spending by Service, FY 2012. (Kaiser Family Foundation) accessed September 2014. https://www.kff.org/medicaid/state-indicator/distribution-of-medicaid-spending-by-service/.
The “Program of all All-Inclusive Care for the Elderly” (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 participants' needs.
The “Program of all All-Inclusive Care for the Elderly” (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 participants' needs.
Governor Dannel P. Malloy, Gov. Malloy Announces $9 Million in Nursing Home “Rebalancing” Grants, (Office of the Governor of Connecticut, March 21, 2014.) http://www.governor.ct.gov/malloy/cwp/view.asp?A=4010&Q=542054.
“Conflict-free case management” assures, in part, that the person or entity that conducts the functional assessment and/or case management services for a member does not also provide services to that individual.
Single points of entry (SPOE) systems offer consumers one-stop access to information, support, and linkages to local care services thereby reducing service fragmentation and simplifying access to long-term supports and services.
A reduction of in-home supportive services hours reported by California for FY 2014 has been recorded as a benefit change.
States can implement this option through a SPA or waiver. An enhanced FMAP is available and varies depending on the share of long term care spending dedicated to HCBS in 2009 ranging from an additional 5 percent for states that dedicated less than 25 percent of their long term care spending on HCBS in 2009 and an additional 2 percent for states that spent between 25 and 50 percent of long term care spending on HCBS in 2009.
New Hampshire and Ohio had applications for the BIP program approved prior to FY 2015.
77 Fed. Reg. 26828 (May 7, 2012).
State of California Health and Human Services Agency, California Receives First-in-the-Nation Approval of New Community-Based Care Option for At-Risk Seniors and Persons with Disabilities. (Sacramento, CA: State of California Health and Human Services Agency,) September 4, 2012. http://www.cdss.ca.gov/cdssweb/default.htm.
CMS Fact Sheet: Summary of Key Provisions of the Home and Community-Based Services (HCBS) Settings Final Rule (CMS 2249-F/2296-F), January 10, 2014.
States’ efforts to expand HCBS options for LTSS are driven in part by the United States Supreme Court’s 1999 decision in Olmstead v. L.C., which found that the unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act.
Provider Rates and Taxes or Fees
Rates for FY 2015 not yet determined at the time of the survey included MCO rates for North Dakota and Wisconsin, inpatient hospital, rates for Wisconsin, and nursing home rates for Alaska. North Carolina did not provide responses for FY 2015.
New Mexico reported an existing MCO provider tax that is tied to their Medicaid’ Insurance Pool, a high risk pool program. The state also reported a new MCO tax added in FY 2014 as well.
Benefits Changes
Centers for Medicare and Medicaid Services, Letter of waiver approval to Secretary Mackereth, August 28, 2014. http://www.healthypa.com/.
Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Indiana through HIP 2.0, (Kaiser Family Foundation, September 2014.) https://www.kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in-indiana-through-hip-2-0/.
- Positive changes counted in this report are denoted with (+). Negative changes counted in this report are denoted with (-). Changes that were not counted as positive or negative in this report, but were mentioned by states in their responses, are denoted with (nc).
- Ibid.
- Centers for Medicare and Medicaid Services, Letter of waiver approval to Secretary Mackereth, August 28, 2014. http://www.healthypa.com/.
Premiums and Cost-sharing
Pennsylvania, as part of their waiver, will apply existing cost-sharing requirements to the new expansion population. This change is reported as new in the table, but is not included in the counts of increases.
Ibid.
Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Indiana through HIP 2.0, (Kaiser Family Foundation, September 2014.) https://www.kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in-indiana-through-hip-2-0/.
- New premiums or copayments as well as new requirements such as making copayments enforceable are denoted as (NEW). Increases in existing premiums or copayments are denoted as (Increased), while decreases are denoted as (Decreased) and eliminations are denoted as (Eliminated).Entries marked as (Proposed) require waiver approval from CMS to implement.
Prescription Drug Utilization and Cost Control Initiatives
In accordance with federal and state law, states pay the lower of (a) the ingredient cost rate plus a dispensing fee; (b) the Federal Upper Limit (FUL) or State Maximum Allowable Cost rate, if applicable, plus a dispensing fee; or (c) the pharmacy’s Usual and Customary Charge.
“Post AWP Pharmacy Pricing and Reimbursement,” American Medicaid Pharmacy Administrators Association and National Association of State Medicaid Directors, White Paper, June 2010.
CMCS Informational Bulletin, “Medicaid Pharmacy – Survey of Retail Prices,” May 31, 2012. http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-05-31-12.pdf.
Alaska reported plans to adopt NADAC pricing for only its State Maximum Allowable Cost list drugs.
Express Scripts, The 2013 Drug Trend Report, (Express Scripts, April 2014). http://lab.express-scripts.com/drug-trend-report/.
The Express Scripts Lab, The 2013 Drug Trend Report Highlights, (Express Scripts, April 2014.) http://lab.express-scripts.com/drug-trend-report/~/media/ace07d91fe7643f6ae2bb9aef764905d.ashx.
Chris Kardish, “The Risky Business of Limiting Medicaid Access to Sovaldi.” (Governing, August 19, 2014.) http://www.governing.com/topics/health-human-services/gov-hepatitis-coverage-solvaldi-lawsuits.html.
Express Scripts, State Governments May Spend $55 Billion on Hepatitis C Medications, (Express Scripts, July 2014.) http://lab.express-scripts.com/insights/specialty-medications/~/media/44c9ff2df0fb463d9c48a4fa4837d367.ashx
Tricia Neuman, Jack Hoadley, and Juliette Cubanski. “The Cost of a Cure: Medicare’s Role in Treating Hepatitis C.” (Health Affairs, June 5, 2014.) http://healthaffairs.org/blog/2014/06/05/the-cost-of-a-cure-medicares-role-in-treating-hepatitis-c/.
Program Integrity Initiatives
Kaiser Commission on Medicaid and the Uninsured, Program Integrity in Medicaid: A Primer. (Kaiser Family Foundation, July 2012.) http://www.kff.org/medicaid/8337.cfm.
HHS announces new tools and resources from the Affordable Care Act…, HHS News Release, September 20, 2010, available at http://wayback.archive-it.org/3926/20131018160558/http://www.hhs.gov/news/press/2010pres/09/20100920e.html.
National Association of Medicaid Directors, Medicaid Managed Care Modernization: Employing New Tools and Efficiencies to Strengthen Program Integrity, (National Association of Medicaid Directors, September 2014.) http://medicaiddirectors.org/sites/medicaiddirectors.org/files/public/namd_mmc_pi_modernization_proposals_140902.pdf.
Ibid.
The Public Assistance Reporting Information System (PARIS) is a federal and state partnership that collects, houses and matches public assistance eligibility information to improve program integrity among participating states.
Medicaid Administration and Priorities
Eileen Griffin, Trish Riley, Vikki Wachino and Robin Rudowitz. Managing a High Performance Medicaid System. (Kaiser Commission on Medicaid and the Uninsured, October 2013.) https://www.kff.org/medicaid/report/managing-a-high-performing-medicaid-program/.
See Forthcoming NAMD report from its Survey of Medicaid Operations. http://www.medicaiddirectors.org.
Methodology
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.
