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An Early Look at Medicaid Expansion Waiver Implementation in Michigan and Indiana

Executive Summary
  1. CMS Letter to Joseph Moser, Medicaid Director, Indiana Family and Social Services Administration, November 25, 2016. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-nemt-temp-ext-ltr-11252016.pdf

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  2. See, e.g.,  Robin Cohen, Michael Martinez, and Emily Zammitti, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2015, (Hyattsville, MD: National Center for Health Statistics, May 2016), http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf, (noting significant difference in non-elderly adult uninsured rate from 2013 to 2015 in the following states that had traditional Medicaid expansions:  AZ (-9.6%), CA (-12.6%), CO (-9.8), IL (-7.9), KY (-15.7%), MD (-7.1%), NH (-7.8%), NV (-14.2%), NJ (-7.3%), NY (-6.6%), OH (-7.0%), OR, (-8.7%), PA (-5.5%), RI (-6.8%), WA (-12.3%), and WV (-19.9%)); Benjamin D. Sommers et al., Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act, 314 JAMA 366  (July 28, 2015), http://jama.jamanetwork.com/article.aspx?articleid=2411283 (finding that lacking a personal physician and limited access to medications both declined significantly more in expansion states than in non-expansion states).

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  3. Kaiser Family Foundation, Key Medicaid Questions Post-Election (Nov. 2016), http://kff.org/medicaid/fact-sheet/key-medicaid-questions-post-election/.

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Key Provisions
  1. The other five states using waivers are Arizona, Arkansas, Iowa, Montana, and New Hampshire.

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  2. The enhanced federal match for expansion adults in 2017 is 95%.

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  3. Technically, Indiana considers these payments to be contributions to the health account deductible and not premiums.

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  4. Deductible funds are not applied to preventive services.

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  5. CMS Letter to Joseph Moser, Medicaid Director, Indiana Family and Social Services Administration, November 25, 2016. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-nemt-temp-ext-ltr-11252016.pdf

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Key Findings
  1. Robin Cohen, Michael Martinez, and Emily Zammitti, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2015, (Hyattsville, MD: National Center for Health Statistics, May 2016), http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf.

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  2. Michigan Department of Health and Human Services (MDHHS), Healthy Michigan Plan Waiver Enrollees, (December, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-dec-mnthly-enrllmnt-rpt-1172017.pdf.

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  3. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 8/2016-10/2016, (Indianapolis, IN: FSSA, December 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12302016.pdf.

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  4. State of Michigan, Healthy Michigan Open Enrollment to Begin April 1, Press Release, (Lansing, MI: State of Michigan Executive Office, March 20, 2014), https://drive.google.com/file/d/0Bx4lt2rIHSK0N1BKaGJHby1EWGM/edit; The Lewin Group, Indiana Healthy Indiana Plan 2.0: Interim Evaluation Report, Prepared for FSSA, (Falls Church, VA: Lewin Group, July 6, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf.

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  5. A total of nearly 130,000 beneficiaries initially transferred into HIP 2.0, including traditional and expansion populations. Indiana Family & Social Services Administration, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 11/2015-1/2016, (Indianapolis, IN: FSSA, March 31, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-nov-jan-2016-03312016.pdf.

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  6. FSSA, Healthy Indiana Plan, Passive Verification Report, (Indianapolis, IN: FSSA, August 31, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-passive-verification-rpt-08312015.pdf.

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  7. University of Michigan, Institute for Healthcare Policy and Innovation, Healthy Michigan Voices Beneficiary Survey Interim Report at 5, 13 (Sept. 15, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-benef-survey-interim-report-09212016.pdf.; University of Michigan, Michigan Institute for Healthcare Policy and Innovation, Primary Care Practitioners’ Views of the Impact of the Healthy Michigan Plan Final Report at iii, iv, v (April 27, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-impact-final-rpt-08022016.pdf.

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  8. Michigan Adult Coverage Demonstration, Section 1115 Quarterly Report (7/1/16-9/30/16) at 11, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-09202016.pdf.

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  9. Enrollees calling about account statements also asked about amounts owed and for clarification about the statement contents.  Id. at 9. 

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  10. MDHHS, MI Health Account Executive Summary Report , (Lansing, MI: MDHHS, October 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-jul-sep-2016.pdf.

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  11. Id.

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  12. MDHHS, Michigan Adult Coverage Demonstration Section 1115 Quarterly Report, 7/1/16-9/30/16, (Lansing, MI: MDHHS, January 17, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-jul-sep-2016.pdf.

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  13. University of Michigan Institute for Healthcare Policy and Innovation, MI Health Account Statements:  Early Experiences of Beneficiaries Report Summary (Ann Arbor, MI: University of Michigan Institute for Healthcare Policy and Innovation, September 14, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-annual-report-DY6.pdf.

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  14. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 8/2016-10/2016, (Indianapolis, IN: FSSA, December 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12302016.pdf.

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  15. Id.

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  16. CMS denied Indiana’s request to lock beneficiaries at all income levels out of coverage for six months for failure to complete the eligibility renewal process timely noting that this is inconsistent with Medicaid’s objective of ensuring access to coverage and does not account for challenges that people with low incomes may face in complying with renewals, such as language access issues, difficulties obtaining mail, disabilities, and homelessness.   CMS, State Demonstrations Group, (Baltimore, MD: CMS, July 29, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-lockouts-redetermination-07292016.pdf.

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  17. FSSA, HIP CMS Metrics, (Indianapolis, IN: FSSA, July 20, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-monthly-rpt-july-2016-07202016.pdf.

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  18. FSSA, Healthy Indiana Plan Demonstration Annual Report, 1/1/15-1/31/16, (Indianapolis, IN: FSSA, April 29, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-annl-rpt-feb-jan-2016-04292016.pdf.

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  19. The Lewin Group, Indiana Healthy Indiana Plan 2.0: Interim Evaluation Report, Prepared for FSSA, (Falls Church, VA: Lewin Group, July 6, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf.

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  20. Id. at 40.

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  21. Kaiser Family Foundation, Premiums and Cost-Sharing in Medicaid:  A Review of Research Findings (Feb. 2013), http://kff.org/medicaid/issue-brief/premiums-and-cost-sharing-in-medicaid-a-review-of-research-findings/.

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  22. FSSA, HIP CMS Metrics, (Indianapolis, IN: FSSA, July 20, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-monthly-rpt-july-2016-07202016.pdf.

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  23. The Lewin Group, Indiana Healthy Indiana Plan 2.0: Interim Evaluation Report, Prepared for the Indiana Family and Social Services Administration (FSSA) at 20 (Falls Church, VA: Lewin Group, July 6, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf.

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  24. Id.

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  25. FSSA, Healthy Indiana Plan, Section 1115 Quarterly Report, 5/15-7/15, (Indianapolis, IN: FSSA, October 8, 2015, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-may-july-10082015.pdf.

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  26. The Lewin Group, Indiana Healthy Indiana Plan 2.0: Interim Evaluation Report, Prepared for FSSA, (Falls Church, VA: Lewin Group, July 6, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf.

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  27. These issues appeared to be more pronounced for those sending money orders by mail as opposed to using a credit or debit card online at the time of application.

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  28. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 8/2016-10/2016, (Indianapolis, IN: FSSA, December 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12302016.pdf.

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  29. See also FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 2/15-4/15, (Indianapolis, IN: FSSA, August 5, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-feb-apr-2015.pdf.

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  30. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 8/2016-10/2016, (Indianapolis, IN: FSSA, December 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12302016.pdf.; FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 2/2016-4/2016, (Indianapolis, IN: FSSA, June 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-feb-apr-06302016.pdf; FSSA, Healthy Indiana Plan, Section 1115 Quarterly Report, 5/15-7/15, (Indianapolis, IN: FSSA, October 8, 2015, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-may-july-10082015.pdf.

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  31. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 8/2016-10/2016, (Indianapolis, IN: FSSA, December 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12302016.pdf.

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  32. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 2/2016-4/2016, (Indianapolis, IN: FSSA, June 30, 2016) at 26, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-feb-apr-06302016.pdf.

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  33. FSSA, Healthy Indiana Plan, Prior Claims Payment Program Report at 4 (Indianapolis, IN: FSSA, October 27, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-prior-claims-pymt-rpt-10272015.pdf.

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  34. Centers for Medicare & Medicaid Services (CMS), State Demonstrations Group, (Baltimore, MD: CMS, July 29, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-lockouts-redetermination-07292016.pdf.

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  35. Id.

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  36. Michigan Adult Coverage Demonstration, Section 1115 Quarterly Report (7/1/16-9/30/16) at 10, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-jul-sep-2016.pdf.

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  37. This waiver authority lasts for two years, from February 2016 through January 2018.  Letter from Eliot Fishman, CMS to Joseph Moser, Indiana Medicaid Director (September 16, 2016).

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  38. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 2/2016-4/2016, (Indianapolis, IN: FSSA, June 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-feb-apr-06302016.pdf.

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  39. FSSA, Healthy Indiana Plan Demonstration, Section 1115 Quarterly Report, 8/2016-10/2016, (Indianapolis, IN: FSSA, December 30, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12302016.pdf.

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  40. FSSA, Healthy Indiana Plan Demonstration, Annual Report, 2/1/15-1/31/16, (Indianapolis, IN: FSSA, April 29, 2016), (citing Oct. 2014 annual report and interim evaluation based on HIP 1.0), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-feb-apr-06302016.pdf.

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  41. University of Michigan Institute for Healthcare Policy and Innovation, MI Health Account Statements:  Early Experiences of Beneficiaries Report Summary at 2, 5 (Sept. 14, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-annual-report-DY6.pdf.

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  42. Id.

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  43. Indiana has allowed providers to scan beneficiaries’ POWER account cards for reimbursement since October, 2015.  FSSA, Healthy Indiana Plan, Section 1115 Quarterly Report, 8/15-10/31/15, (Indianapolis, IN: FSSA, December 29, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-aug-oct-12292015.pdf.

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  44. MDHHS, Healthy Michigan Plan – Health Risk Assessment Report, (Lansing, MI: MDHSS, September, 2016), at 13, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-jul-sep-2016.pdf.

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  45. MDHHS, Healthy Michigan Plan Progress Report, (Lansing, MI: MDHHS, September 6, 2016), http://www.michigan.gov/documents/mdch/Website_Healthy_Michigan_Plan_Progress_Report_12-01-2014_475355_7.pdf

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  46. MDHHS, Performance Monitoring Report, Medicaid Managed Care Healthy Michigan Plan Adult Core Set Measures, Composite – All Plans (Lansing, MI: MDHHS, October 2016, revised November 2016), at 25,  https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-annual-report-DY6.pdf.

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  47. University of Michigan, Michigan Institute for Healthcare Policy and Innovation, Primary Care Practitioners’ Views of the Impact of the Healthy Michigan Plan Final Report at v (April 27, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-impact-final-rpt-08022016.pdf.

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  48. MDHHS, Healthy Michigan Plan – Health Risk Assessment Report, (Lansing, MI: MDHSS, September, 2016), at 13, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-jul-sep-2016.pdf.

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  49. The Lewin Group, Indiana Healthy Indiana Plan 2.0: Interim Evaluation Report, Prepared for FSSA, (Falls Church, VA: Lewin Group, July 6, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-interim-evl-rpt-07062016.pdf.

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  50. Michigan Adult Coverage Demonstration, Section 1115 Quarterly Report, 7/1/2016-9/30/16 at 16 (Jan. 17, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-qtrly-rpt-jul-sep-2016.pdf.

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  51. Susan Dorr Goold et. al., Healthy Michigan Voices Beneficiary Survey Interim Report, (Ann Arbor, MI: University of Michigan Institute for Healthcare Policy & Innovation, September 15, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/Healthy-Michigan/mi-healthy-michigan-benef-survey-interim-report-09212016.pdf.

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  52. FSSA, HIP CMS Metrics, (Indianapolis, IN: FSSA, July 20, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-monthly-rpt-july-2016-07202016.pdf.

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  53. The state’s NEMT waiver evaluation found “no evidence” that HIP 2.0 beneficiaries without NEMT were more likely to miss appointments due to transportation or other reasons compared to HIP 2.0 beneficiaries enrolled in the one health plan that does offer NEMT as a value-added benefit. Even with the NEMT waiver, about two-thirds of the HIP 2.0 population does receive NEMT, either because they are exempt from the NEMT waiver (pregnant, medically frail, and mandatory parents, 19 and 20 year olds, and those receiving Transitional Medical Assistance) or because they belong to the one health plan that separately offers the benefit as a managed care value-added service to its enrollees. The Lewin Group, Indiana HIP 2.0: Evaluation of Non-Emergency Medical Transportation (NEMT) Waiver, at ES-2, ES-1, Prepared for FSSA, (Fairfax, VA: November 2, 2016),  https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-nemt-final-evl-rpt-11022016.pdf.

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  54. Id. at ES-2.

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  55. Id. at ES-3.

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  56. Id. at ES-3, ES-4.

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  57. The Gateway to Work call center opened in May, 2015, and as of January 2016, had received 3,227 calls FSSA, Healthy Indiana Plan Demonstration Annual Report, (Indianapolis, IN: FSSA, April 29, 2016). https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-qtrly-rpt-feb-apr-06302016.pdf.

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  58. See, e.g.,  Robin Cohen, Michael Martinez, and Emily Zammitti, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2015, (Hyattsville, MD: National Center for Health Statistics, May 2016), http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf, (noting significant difference in non-elderly adult uninsured rate from 2013 to 2015 in the following states that had traditional Medicaid expansions:  AZ (-9.6%), CA (-12.6%), CO (-9.8), IL (-7.9), KY (-15.7%), MD (-7.1%), NH (-7.8%), NV (-14.2%), NJ (-7.3%), NY (-6.6%), OH (-7.0%), OR, (-8.7%), PA (-5.5%), RI (-6.8%), WA (-12.3%), and WV (-19.9%)); Benjamin D. Sommers et al., Changes in Self-reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act, 314 JAMA 366  (July 28, 2015), http://jama.jamanetwork.com/article.aspx?articleid=2411283 (finding that lacking a personal physician and limited access to medications both declined significantly more in expansion states than in non-expansion states).

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  59. Kaiser Family Foundation, Key Medicaid Questions Post-Election (Nov. 2016), http://kff.org/medicaid/fact-sheet/key-medicaid-questions-post-election/.

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