From Ballot Initiative to Waivers: What is the Status of Medicaid Expansion in Utah?
Issue Brief
CMS statement released July 29, 2019 and CMS letter to Governor Herbert on August 16, 2019: https://www.cms.gov/newsroom/press-releases/cms-statement-partial-medicaid-expansion-policy, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/per-capita-cap/ut-per-capita-cap-correspondence-ltr-20190816.pdf
Under a full expansion, certain Targeted Adult populations currently covered through state waivers would transition to coverage under the expansion group.
The March 2019 waiver amendment was approved based on the state’s June 2018 pending amendment request, which sought to cover adults ages 19 to 64 up to 95% FPL (effectively 100% FPL with the 5 percentage point FPL disregard) at the ACA enhanced match with an enrollment cap and a work requirement. The June 2018 waiver amendment request also sought to waive EPSDT for 19 and 20 year olds and authority for mandatory Medicaid premium assistance for individuals with access to employer sponsored insurance.
Utah’s waiver continues to cover the Targeted Adult population, which was added in 2017, and includes adults ages 19-64 without dependent children with income up to 5% FPL who are chronically homeless or involved in the criminal justice system and in need of substance use or mental health treatment. The waiver provides that the Targeted Adult group or any subset may be closed to new enrollment at the state’s election.
Members of the Adult Expansion Population who are childless adults receive full state plan benefits. Members of the Adult Expansion Population who are parent/caretakers receive the same benefit package as traditional low-income parents under Utah’s waiver, which is more limited than Utah’s state plan benefit package. For example, private duty nursing, long-term care, eyeglasses, and non-emergency medical transportation are not covered, and dental services are generally covered only in emergencies. There also are additional surgical exclusions, a limit of 16 physical and occupational therapy visits per year, hearing aids only for congenital hearing loss, and some excluded medical supplies and equipment. Utah’s waiver continues to not provide EPSDT treatment services for 19 and 20 year olds. In addition, the March 2019 waiver amendment authorizes services for all Medicaid-eligible individuals who are primarily receiving substance use disorder treatment and withdrawal management services as short-term “institution for mental disease” residents. Individuals in the Adult Expansion Population with access to employer sponsored insurance must enroll in that coverage and receive Medicaid premium assistance as of January 1, 2020. If an individual misses the period to enroll in employer-sponsored insurance, they are ineligible for Medicaid. Individuals must pay employer-sponsored insurance premiums out-of-pocket and will be reimbursed by the state, minus the Medicaid premium applied to those from 101-138% FPL that the state is seeking in the Fallback waiver amendment.
UT Dep’t of Health, Utah’s Medicaid Expansion Implementation Toolkit at 2.
Benjamin Wood, Salt Lake Tribune, “Lawmakers’ rejection of Proposition 3 is costing Utahns $2.5M each month, state Medicaid director says” (August 23, 2019), https://www.sltrib.com/news/politics/2019/08/23/lawmakers-rejection/.
The approval came two days after a federal district court set aside waivers in Arkansas and Kentucky that included work and reporting requirements. The case is now on appeal.
The request for the enhanced ACA match would also apply to the Targeted Adult population.
CMS statement released July 29, 2019, https://www.cms.gov/newsroom/press-releases/cms-statement-partial-medicaid-expansion-policy.
CMS guidance issued in 2012 concludes that “Congress directed that the enhanced matching rate be used to expand coverage to [138%] of FPL. The law does not provide for a phased-in or partial expansion.”, https://www.cms.gov/CCIIO/Resources/Files/Downloads/exchanges-faqs-12-10-2012.pdf
CMS letter to Utah Governor Gary Herbert on August 16, 2019, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/per-capita-cap/ut-per-capita-cap-correspondence-ltr-20190816.pdf.
Some expenditures would be excluded from the per capita caps including emergency only funding for non-citizens, expenditures for enrollees in federally recognized tribes and inpatient stays for incarcerated individuals.
A number of enrollment groups are included in the overall waiver and subject to budget neutrality calculations, but excluded from the per capita cap funding calculations.
Utah submitted the Fallback Plan waiver as an amendment to the state’s already-approved PCN waiver (unlike the PCC waiver, which it submitted as a new, separate waiver).
CMS letter to Utah Governor Gary Herbert on August 16, 2019, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ut/per-capita-cap/ut-per-capita-cap-correspondence-ltr-20190816.pdf.
Under long-standing federal policy, Section 1115 waivers must be budget neutral to the federal government, meaning that federal costs under the waiver cannot exceed what federal costs would have been without the waiver.
Covered services included primary care physician, lab, radiology, durable medical equipment, emergency room services, pharmacy, dental, and vision, often with different limitations than the state plan benefit package. Inpatient hospital, specialty care, and mental health services were not covered.
UT Dep’t of Health, Utah’s Medicaid Expansion Implementation Toolkit at 3.
The full expansion also would provide traditional Medicaid benefits under an alternative benefit plan as required under the ACA. It would not limit benefits for expansion parents as described in endnote 3 and would not waive EPSDT for 19 and 20 year olds.