Key State Policy Choices About Medical Frailty Determinations for Medicaid Expansion Adults

Issue Brief
  1. For other survey findings, including state-level data on Medicaid financial eligibility criteria and adoption of key age and disability-related pathways, options to expand financial eligibility for Medicaid long-term services and supports, Medicaid assistance with out-of-pocket costs for low-income Medicare beneficiaries, state choices about whether to adopt optional age and disability-related pathways in light of states’ ACA expansion status, and state adoption of optional streamlined eligibility renewal procedures, see Kaiser Family Foundation, Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey (June 2019), https://www.kff.org/medicaid/issue-brief/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey/.

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  2. Medically frail children must include those under 19 who are eligible for SSI, eligible under the Katie Becket option, in foster care or another out-of-home placement, receiving foster care or adoption assistance, or receiving services through a family-centered, community-based, coordinated care system receiving maternal and child health funds and those with serious emotional disturbances. 42 C.F.R. § 440.315 (f).

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  3. 42 U.S.C. § 1396a (k)(1); 42 C.F.R. § § 440.370, 440.380 (noting that states have the option to provide benchmark coverage to beneficiaries without regard to comparability or statewideness). The statute uses the former terminology, “benchmark benefits.” In its July 2013 final rule, CMS began using the term “ABP.” 78 Fed. Reg. 42160 (July 15, 2013).

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  4. 42 U.S.C. § 1396u-7; 42 C.F.R. § § 440.300-440.390; 45 C.F.R. Part 156.

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  5. Most adult Medicaid enrollees receive the state plan benefit package, which includes certain services that all states participating in Medicaid must cover and any optional services that the state chooses to cover. 42 U.S.C. § § 1396a (a)(10); 1396d (a)(1)-(29); 1396n (g), (i), (j), (k); 1396w-4.

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  6. The process for doing so is summarized at 78 Fed. Reg. 42238.

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  7. State plan HCBS include those available under the § 1915 (i) state plan option, § 1915 (j) self-directed personal assistance services, and § 1915 (k) Community First Choice attendant services and supports. 42 C.F.R. § 440.330 (d).

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  8. 42 C.F.R. § 440.345(d). The specific services in each EHB category are determined by those that are included in the commercial insurance plan that the state selects as its EHB benchmark. An EHB benchmark is one of several commercial insurance plans that the state selects and may differ from the state’s ABP benchmark. If the state’s EHB benchmark plan does not include any services within an entire EHB category, the state supplements the ABP by including all of the services in that category from another of the EHB benchmark plan choices. However, if the state’s EHB benchmark plan does not include any habilitative services, the state instead may choose to define the scope of that coverage for the expansion ABP. After the state determines the contents of the 10 EHB categories for its expansion adult ABP, the state then may substitute actuarially equivalent benefits within a single EHB category.

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  9. 42 C.F.R. § 440.345 (a).

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  10. 42 C.F.R. § 440.345 (b).

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  11. 42 C.F.R. § 440.365.

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  12. 42 C.F.R. § 440.390.

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  13. 42 C.F.R. § § 440.345 (c).

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  14. Kaiser Family Foundation, Benefits and Cost-sharing for People with Disabilities in Medicaid and the Marketplace (Oct. 2014), https://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.

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  15. Kaiser Family Foundation, Adult Behavioral Health Benefits in Medicaid and the Marketplace (June 2015), https://www.kff.org/medicaid/report/adult-behavioral-health-benefits-in-medicaid-and-the-marketplace/.

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  16. 42 C.F.R. § 440.345 (f). Other populations that cannot be required to enroll in an ABP and instead must have access to the full state plan benefit package include people who are blind or have disabilities (regardless of whether they are eligible for SSI); children with disabilities eligible under the Katie Beckett state plan option; people dually eligible for Medicare and Medicaid; people who are terminally ill and receiving hospice care; people who live in institutions and receive only a personal needs allowance; people with developmental disabilities and seniors who qualify for nursing facility or equivalent institutional services or home and community-based waiver services; women receiving treatment for breast or cervical cancer; people who qualify for Medicaid based on TB infection; and people who qualify for Medicaid as medically needy based on a spend down. 42 U.S.C. § 1396a (k)(1). Technically, beneficiaries in the adult expansion group who meet an ABP exemption “must be given the option of an Alternative Benefit Plan that includes all benefits available under the approved State plan” instead of being required to receive the ABP that the state has selected for the expansion group. 42 C.F.R. § 440.315. Exempt beneficiaries must have access to the full Medicaid state plan benefit package unless they instead choose to receive the expansion adult ABP. States must inform exempt beneficiaries about how benefits and cost-sharing in the expansion adult ABP compares to the benefits and cost-sharing in the Medicaid state plan and how to enroll in and disenroll from the expansion adult ABP. 42 C.F.R. § 440.320.

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  17. See, e.g., AZ SPA #14-006 (April 1, 2014) (noting that providing newly eligible adults with full state plan benefits “will help minimize disruptions for individuals who move among different eligibility categories”); CO SPA #13-0055 (Feb. 10, 2014) (noting that the ABP benchmark plan is the same as the Marketplace benchmark plan and that offering state plan services in the expansion ABP will “ease transitions as clients churn”); OR SPA #13-0019 (Jan. 9, 2014) (noting that the EHB benchmark plans in the ABP and Marketplace are the same and that aligning the ABP with state plan benefits will help minimize disruptions for people who move among benefit packages).

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  18. ACA expansion adults are a mandatory coverage group in the statute, although the Supreme Court’s 2012 ruling on the ACA’s constitutionality effectively made adoption of the expansion optional for states. Kaiser Family Foundation, A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion (Aug. 2012), https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/.

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  19. U.S. Census Bureau, How Disability Data are Collected from the American Community Survey, (Oct. 17, 2017), https://www.census.gov/topics/health/disability/guidance/data-collection-acs.html.

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  20. SSI beneficiaries have an impaired ability to work at a substantial gainful level as a result of old age or significant disability.

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  21. The maximum SSI benefit is 74% of the federal poverty level (FPL, $9,252/year for an individual in 2019), and the asset limit for an individual is $2,000. The ACA Medicaid expansion covers individuals up to 138% FPL ($17,236/year for an individual in 2019) without an asset test in states that opt to adopt it. States also have the option to extend financial eligibility for disability-related Medicaid coverage pathways up to 300% of SSI ($27,756/year for an individual in 2019).

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  22. People with disabilities may qualify for Medicaid in traditional poverty-related pathways (such as low-income parents or children), although financial eligibility limits for adults in non-expansion states remain low. Under the ACA, all children in families with income up to 138% FPL are eligible for Medicaid regardless of whether they have a disability. However, the median financial eligibility limit for parents in non-expansion states is 40% FPL ($693 per month for a family of 3 in 2018; $711/month for a family of 3 in 2019), and only one non-expansion state (WI) offers any pathway to coverage based solely on low income for childless adults as of January 2019. Kaiser Family Foundation, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey (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/.

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  23. Qualifying for Medicaid based solely on low income as an expansion adult can mean quicker access to coverage, without waiting for a disability determination. States have 90 days to determine Medicaid eligibility in disability-related pathways. Kaiser Family Foundation, The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities (April 2014), https://www.kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/. By contrast, real-time eligibility determinations are available in most states for poverty-related pathways. Kaiser Family Foundation, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey (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/. If someone who qualifies through the ACA expansion group is later also determined to be eligible through a disability-related pathway, the person can choose whether to remain in the expansion group or switch to the disability-related group. 42 C.F.R. § 435.911 (c) (2), (d); see also Kaiser Family Foundation, The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities (April 2014), https://www.kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.

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  24. Five states (ID, KY, NE, UT, and VA) did not respond to these survey questions. Survey results have been supplemented by information from state plan amendments (SPAs), Section 1115 waiver documents, and state legislation to determine that medical frailty determinations currently are not required in these states. Kentucky and Virginia align their expansion adult ABP with the state plan benefit package, making a medical frailty determination unnecessary. Kentucky Medicaid Alternative Benefit Plan, SPA #KY-13-020 (approved Dec. 20, 2013), https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/KY/KY-13-020-ABPSPA.pdf; Virginia Medicaid Alternative Benefit Plan, SPA #18-0008 (effective Jan 1, 2019), https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/VA/VA-18-0008.pdf. Kentucky’s Section 1115 waiver, which placed additional restrictions such as a work requirement and premiums on expansion adults (as well as some traditional adults) has been set aside by a court; if and when that waiver is allowed to be implemented, the waiver calls for Kentucky to exempt medically frail enrollees from those restrictions. See generally Kaiser Family Foundation, Ask KFF: MaryBeth Musumeci Answers 3 Questions on Kentucky, Arkansas Medicaid Work and Reporting Requirements (April 2019), https://www.kff.org/medicaid/issue-brief/ask-kff-marybeth-musumeci-answers-3-questions-on-kentucky-arkansas-medicaid-work-and-reporting-requirement-cases/; Kaiser Family Foundation, Re-approval of Kentucky’s Medicaid Demonstration Waiver (Nov. 2018), https://www.kff.org/medicaid/issue-brief/re-approval-of-kentucky-medicaid-demonstration-waiver/. Virginia has a pending Section 1115 Medicaid waiver application that could require the state to determine medical frailty to exempt individuals from restrictive provisions, such as a work requirement and premiums, if approved by CMS. Kaiser Family Foundation, Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State (April 18, 2019), https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/. Utah’s Section 1115 demonstration waiver does not require a determination of medical frailty. For more information about Medicaid expansion in UT, see Kaiser Family Foundation, From Ballot Initiative to Waivers: What is the Status of Medicaid Expansion in Utah? (April 2019), https://www.kff.org/medicaid/issue-brief/from-ballot-initiative-to-waivers-what-is-the-status-of-medicaid-expansion-in-utah/. Idaho and Nebraska have adopted but not yet implemented the Medicaid expansion; state legislation calls for those states to pursue Section 1115 waivers that, if approved by CMS, would impose eligibility restrictions that may require a medical frailty determination. See generally Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision (May 13, 2019).

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  25. Two other states (AZ and OH) have approved Section 1115 waivers that will require a medical frailty determination when implemented. In addition, KY’s waiver has restrictions that would require a medical frailty determination, but that waiver has been set aside by a court and has not yet been implemented. AR also has additional waiver provisions that exempt medically frail enrollees but have been set aside by a court. See generally Kaiser Family Foundation, Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State (April 18, 2019), https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/.

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  26. Medically frail enrollees are exempt from prior authorization requirements.

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  27. Medically frail enrollees retain access to NEMT, which is waived for other enrollees.

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  28. However, medically frail enrollees are still disenrolled from coverage for failure to timely renew eligibility.

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  29. Five states (CA, MI, NV, NH, and WV) were unable to report this data.

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  30. NH did not respond to this question as it accepts enrollee self-attestation for medical frailty.

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  31. 130 CMR 505.008 (F), https://www.mass.gov/files/documents/2018/01/29/130cmr505.pdf.

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  32. Two states (AR and NV) did not respond to this question.

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  33. The other two states (AR and MA) did not respond to this question.

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