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Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin

Appendix Table 1: Key Provisions in Wisconsin’s Proposed Amendment to its BadgerCare Reform
Section 1115 Medicaid Demonstration Waiver
Element Wisconsin Proposed Waiver Amendment
Overview: As directed by state law, seeks to amend existing waiver for childless adults to require monthly premiums for childless adults from 51% to 100% FPL ($8/month per household), with a coverage lock-out of up to 6 months for non-payment; offer premium reductions for completion of a health risk assessment and healthy behavior program; require, as a condition of eligibility, that childless adults complete a drug screening, and if indicated, a drug test at application and renewal; and limit childless adults’ eligibility to 48 months followed by a 6 month lock-out.

Also seeks authority to charge an $8 copay for emergency department utilization by childless adults; exempt childless adults ages 19 to 49 from the 48 month time limit if working or attending job training 80 hours per month; use Medicaid funds to offer job training as a covered benefit for childless adults; and use Medicaid funds to pay for residential substance use disorder treatment up to 90 days in institutions for mental disease for all Medicaid enrollees.

Duration: Would amend existing waiver that is in effect through December 31, 2018. State would implement changes no earlier than one year after approval.
Coverage Groups: Most provisions would apply only to adults without dependent children from 0-100% FPL.

Authority to cover 90-day substance use disorder treatment stays in institutions for mental disease would apply to all Medicaid beneficiaries.

Premiums: Would require childless adults with incomes from 51-100% FPL to pay premiums of $8/month per household.

Failure to pay premiums could result in loss of coverage for up to six months unless outstanding premiums are paid. After six months, individuals could re-enroll in coverage without paying past-due amounts. Third parties (including non-profit organizations, hospitals, provider groups, and employers) could make premium payments for enrollees.

American Indian and Alaska Natives (AI/AN) would be exempt from paying monthly premiums.

Co-Payments: Seeks authority (under Section 1916(f)) to charge childless adults who use the emergency department (ED) an $8 co-pay (would be applicable for all ED use not just non-emergency ED use). Providers would be responsible for collecting co-payments but cannot refuse treatment for nonpayment.

American Indian and Alaska Natives (AI/AN) would be exempt from paying copays.

Healthy Behavior Incentives: Would allow childless adults from 51-100% FPL (who are required to pay premiums) to reduce their premium payments by 50 percent if they complete a health risk assessment (HRA) and do not engage in health risk behaviors based on self-attestation. Those who complete the HRA and engage in health risk behaviors but attest to actively managing their behavior and/or to having a condition beyond their control may have premiums reduced by 50 percent. Health risk behaviors include alcohol consumption, body weight, illicit drug use, seatbelt use, and tobacco use. State would use target measures set by national organizations such as the CDC to determine the threshold for when a behavior becomes a risk. Enrollees would complete the HRA and self-attest to any changed health risk behavior at annual eligibility renewal.
Benefits:  Would use Medicaid funds to cover stays up to 90-days for residential substance use disorder treatment services in “institutions for mental disease” for all Medicaid beneficiaries ages 21-64 (in MCOs and FFS).
Drug Screening and Testing: Would require as a condition of eligibility that childless adults complete a drug screening questionnaire about current and prior substance use and, if indicated, a drug test at application and renewal. Individuals who indicate they are ready to enter treatment on the drug screening questionnaire may forego the drug test and enter treatment. For individuals who test positive for a controlled substance without evidence of a valid prescription, eligibility will be conditioned on completing a substance abuse treatment program. If treatment is not immediately available, Medicaid eligibility continues. Refusal to participate in treatment would result in Medicaid ineligibility but individuals may reapply (at any time) when they are willing to consent to treatment.
Work Requirement: Would require childless adults ages 19 to 49 to work or participate in job training for 80 hours per month. Enrollees would be exempt from the work requirement if diagnosed with a mental illness; receiving Social Security Disability; serving as primary caregiver for a person who cannot care for him/herself; physically or mentally unable to work; receiving or applied for unemployment insurance; taking part in alcohol or drug abuse treatment program; enrolled in an institution of higher learning at least half-time; or attending high school at least halftime. DHS will consider comments to add performing community service and actively seeking work as qualified activities in discussions with CMS and when developing an operational protocol.

Also would use Medicaid funds to pay for costs associated with job training as a covered benefit for childless adults.

Time Limit on Eligibility: Would limit Medicaid enrollment for childless adults to 48 months (beginning the first month the policy goes into effect or upon initial program enrollment). After 48 months, enrollees would be ineligible for Medicaid for six months, but the 48-month time limit would re-start if an individual re-enrolls after the six-month period. Enrollees over age 49 and those that meet the work requirement (described above) would not be subject to the 48-month eligibility limit (the time limit clock would stop during the time a beneficiary works and/or receives job training for at least 80 hours per month). Individuals exempt from the work requirement would also be exempt from the 48-month time limit on eligibility.
Next Steps: State submitted its waiver amendment to CMS on June 7, 2017. The federal public comment period will be open from June 15, 2017 to July 15, 2017.
SOURCE: BadgerCare Reform Demonstration Project Section 1115 Demonstration Waiver Amendment Application, submitted June 7, 2017 and certified as complete on June 15, 2017.
Appendix Table 2: Key Provisions in Maine’s Proposed Section 1115 Medicaid Demonstration Waiver
Element Maine Proposed Waiver
Overview: State seeks waiver to require premiums and work for traditional adults ages 19-64 (such as parents up to 105% FPL, former foster care youth, those receiving Transitional Medical Assistance, and people with breast/cervical cancer) as conditions of eligibility. Work also would be required for those eligible based on HIV status. State also seeks to delay coverage until first day of the month in which a beneficiary makes an initial premium payment. Premium nonpayment (after a grace period of no less than 60 days) would result in a lock-out period of 90 days. Noncompliance with work requirements for more than three months in a 36-month period would result in disenrollment.

State also seeks waiver to apply a $5,000 asset test to all households eligible based solely on low income; impose limits on Medicaid-compliant annuities for long-term care eligibility determinations; eliminate hospitals’ ability to make presumptive eligibility determinations; waive retroactive eligibility; impose a $20 copay for ER use that does not result in an admission; and charge beneficiaries for missed appointments.

Duration: Seeks 5-year waiver (Jan. 1, 2018 through Dec. 31, 2022). Would implement changes 6 months following CMS approval (estimated start: January 1, 2018); however, premiums would be required 6 months later (estimated start: July 1, 2018).
Coverage Groups: Proposed work and premium requirements would apply to traditional adults, ages 19-64, at all income levels,i such as:

-parents from 0-105% FPL (up to $20,420/year for a family of 3 in 2017);
-young adults who have aged out of foster care up to age 26;
-those eligible for family planning services (up to 209% FPL, $42,678/year for a family of 3 in 2017);
-those receiving Transitional Medical Assistance (TMA, for up to one year after leaving cash assistance due to earnings); and
-people with HIV up to 250% FPL ($30,150/year for an individual in 2017)

Individual exemptions discussed under “work requirement” section below apply to both work and premium requirements except that premiums do not apply to HIV group.

All other proposed provisions would apply to all applicants or beneficiaries (as applicable per provision).

Asset Test Seeks authority to apply a $5,000 asset test to all coverage groups that currently do not have an asset test (there is no asset test under current law for coverage groups based solely on low income (vs. old age/disability)).
Limits on Annuities: Seeks authority to impose a transfer penalty for the purchase of Medicaid-compliant annuities for long-term care eligibility determinations and to set a minimum pay out period at 80% of the annuitant’s life.
Presumptive Eligibility: Seeks to remove requirement for hospitals to make presumptive eligibility determinations.
Coverage Effective Date: Would begin coverage on the first day of the month in which a beneficiary makes an initial premium payment instead of the month of application. Beneficiaries would have 60 days from the date of their eligibility determination to make this payment.
Retroactive Coverage: Seeks waiver of retroactive eligibility so that coverage would begin no earlier than 1st day of month of application.
Premiums and Lock-Out for Non-Payment: Would require monthly premiums for traditional adults (such as parents, former foster care youth, those receiving TMA, people with breast/cervical cancer) as follows:

0-100% FPL ($1,701/month for a family of 3 in 2017) = $14

101%-200% FPL ($1,719-$3,403/month) = $43

201% and above ($3,420+/month) = $66

Beneficiaries may be disenrolled for nonpayment of premiums (after a grace period of no less than 60 days) and locked out of coverage for 90 days. Disenrolled beneficiaries may re-enroll after lock-out period only if they pay any past-due amounts.

The same exemptions that apply to the work requirement (described below) apply to premiums. In addition, people eligible based on HIV status are exempt from premiums.

Seeks to charge premiums without regard to the total cost-sharing limit of 5% of income (point-of-service copayments would remain subject to 5% limit)

Co-Payments: Beneficiaries would continue to be subject to point-of-service cost sharing at state plan amounts up to 5% of quarterly household income.

All beneficiaries (except for dual eligible beneficiaries who do not receive full Medicaid benefits) would be subject to $20 copayment for use of the emergency room that does not result in an inpatient admission. The state would collect these payments after periodic claims reviews; payments to providers would not be decreased.

Seeks authority to allow providers to charge beneficiaries for missed appointments, according to the provider’s “standard office policy.” However, the missed appointment fee could not exceed the Medicaid reimbursement amount for the service that would have been delivered.

Work Requirement: Would require traditional adults (such as parents, former foster care youth, those receiving TMA, people with breast/cervical cancer or HIV)) ages 19-64 to meet a work requirement.

The following activities would comply: paid employment at least 20 hours per week (averaged monthly), approved job training program at least 20 hours per week, volunteer work at least 24 hours per month, enrollment at an academic institution at least half time, combination of work and education that meets the 20 hours per week threshold, receive unemployment benefits, or provide caregiver services for a non-dependent person with disability if also coupled with career planning in this area.

Beneficiaries would be exempt from the work requirement (and premium requirement) if they reside in an institutional or residential facility; reside in a residential substance abuse treatment and rehabilitation program; care for a dependent with a disability or dependent under age six; are pregnant; are physically or mentally unable to work 20 or more hours per week; or are receiving temporary or permanent public or private disability benefits.

Time Limit on Eligibility: Coverage for traditional adults (such as parents, former foster care youth, those receiving TMA, people with breast/cervical cancer or HIV) would be limited to no more than 3 months in a 36-month period unless beneficiaries comply with work requirement (described above).  Coverage for an additional month (beyond the three months) may be authorized in exceptional circumstances and the state may provide additional exemptions with a determination of good cause.
Next Steps: The state’s 30-day public comment period closes on May 25, 2017. Public hearings are being held on May 17, 2017 (Portland, ME) and May 18, 2017 (Augusta, ME).
NOTE: i Eligibility groups that would be affected by proposed work requirements and premiums include the following mandatory categorically needy groups: low income families, parents/caretaker relatives, transitional medical assistance (TMA), extended Medicaid due to child or spousal support collections (no work requirement for this group), former foster care children AND the following optional categorically needy groups: certain women needing treatment for breast or cervical cancer, individuals eligible for family planning services, reasonable classifications of individuals under age 21, medically needy individuals age 18 through 20, medically needy parents and other caretaker relatives, and special benefits waiver (HIV waiver) (no premium requirement for this group).

 

Issue Brief

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