Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017
Executive Summary
Centers for Medicare and Medicaid Services. National Health Expenditures (Washington, DC: Centers for Medicare and Medicaid Services, December 2015). http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.
Deborah Dowell, Tamara Haegerich, and Roger Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, 65, no.1 (March 2016): 1-49, http://dx.doi.org/10.15585/mmwr.rr6501e1.
Centers for Medicare and Medicaid Services. National Health Expenditures (Washington, DC: Centers for Medicare and Medicaid Services, December 2015). http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.
Introduction
Ibid.
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.
An archive of previous survey reports is available at: 50-State Medicaid Budget Survey Archives, Kaiser Commission on Medicaid and the Uninsured, accessed October 1, 2016, https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.
Eligibility, Enrollment, Premiums, and Copayments
Missouri plans to replace its family planning waiver with a state-funded family planning coverage program that will not cover or pay for services provided by organizations that also provide abortion services. Women who are eligible for the federally-funded program will continue to be eligible for the state-funded program, without change. The available services will also remain the same but the provider qualifications will be changed.
Missouri Department of Social Services, Public Notice of Suspension of Federal Expenditure Authority for Section 1115 Family Planning Demonstration, entitled “Missouri Woman’s Health Services Program,” (Missouri Department of Social Services, July 2016), https://dss.mo.gov/mhd/waivers/1115-demonstration-waivers/files/missouri-women-health-services-waiver-suspension-notice-phase-out-plan.pdf.
Centers for Medicare and Medicaid Services, To facilitate successful re-entry for individuals transitioning from incarceration to their communities, State Health Official Letter SHO #16-007, (Baltimore, MD: Centers for Medicare and Medicaid Services, April 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/sho16007.pdf.
Ibid.
The Omnibus Budget Reconciliation Act (OBRA) of 1986 established the option for states to cover pregnant women and infants (up to 1 year of age) up to 100 percent of federal poverty level (FPL). OBRA of 1989 mandated coverage for pregnant women and children under age 6 in families with incomes at or below 133 percent of FPL
A key challenge for most states is that there is no common data source for both the total number of births and the number financed by Medicaid. Data on total births generally comes from vital records data maintained by state public health agencies, although at least two states provided information from an all-payer hospital data base.
State results are weighted based on the June 2016 Medicaid and CHIP enrollment in each state.
Arkansas notes that Medicaid has historically funded sixty-six percent of all births in that state. With the implementation of Medicaid expansion, most Medicaid-funded births now occur through the Private Option plans. As a result, the Arkansas the Medicaid agency does not have data on the number of these Medicaid-funded births.
Julia Paradise, Medicaid Moving Forward (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2015), https://www.kff.org/health-reform/issue-brief/medicaid-moving-forward/.
Out of those 44 states, seven states (DC, Idaho, Kentucky, Louisiana, New Mexico, Vermont, and Virginia) report not charging premiums to enrollees in their buy-in programs and four states (Arkansas, Nebraska, New Jersey, and South Dakota) did not respond to the question about premiums.
Iowa has a FOA, but does not charge premiums.
Indiana requires premiums for some non-expansion enrollees.
Robin Rudowitz and MaryBeth Musumeci, The ACA and Medicaid Expansion Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2015), https://www.kff.org/medicaid/issue-brief/the-aca-and-medicaid-expansion-waivers/ .
New Hampshire has a waiver pending to impose copayments for non-emergency use of the emergency department, but this benefit is not covered in the QHP benefit package.
Managed Care Initiatives
Centers for Medicare and Medicaid Services, Medicaid & CHIP Monthly Application, Eligibility Determinations, and Enrollment Reports. (Washington, DC: Centers for Medicare and Medicaid Services, June 2016), http://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html.
Connecticut does not have capitated managed care arrangements, but does carry out many managed care functions, including ASO arrangements, payment incentives based on performance, intensive care management, community workers, educators, and linkages with primary care practices.
Idaho’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. California has a small PCCM program operating in LA County for those with HIV. Three states use PCCM authority to operate specialized programs that are not counted here as PCCM programs: South Carolina uses PCCM authority to provide care management services to approximately 200 medically complex children; the Texas Medicaid Wellness program provides care management services for high-cost/high-risk enrollees, and Wyoming’s Patient Centered Medical Home program uses PCCM authority to make PMPM payments.
Centers for Medicare and Medicaid Services, Medicaid & CHIP Monthly Application, Eligibility Determinations, and Enrollment Reports. (Washington, DC: Centers for Medicare and Medicaid Services, June 2016), http://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html.
California was re-categorized from “Varies” to “Always Mandatory” across all population groups (except for persons with ID/DD) as the state noted that enrollment is generally mandatory across the state with the exception of one, small rural county where managed care is voluntary because there is only 1 plan and it is not a COHS county. The ID/DD population is subject to mandatory enrollment only in COHS counties.
The state had planned to start implementation on January 1, 2016 but implementation was delayed due to delayed approval from CMS to allow the state additional time to complete readiness activities. See Letter from Vikki Wachino, Director Center for Medicaid & CHIP Services to Mikki Stier, Iowa Medicaid Director, February 23, 2016: https://governor.iowa.gov/sites/default/files/documents/CMS%20Letter%20to%20Branstad%20Administration.pdf.
“Medicaid to request July 1, 2017 start for Regional Care Organizations,” Alabama Medicaid Agency, September 14, 2016, http://medicaid.alabama.gov/news_detail.aspx?ID=11768.
81 FR 27497, available at: https://www.gpo.gov/fdsys/granule/FR-2016-05-06/2016-09581.
In the rule, CMS formalizes its policy around “in lieu of,” which is an authority that a number of states were using to cover stays in IMDs prior to this rule. Some of these states must now adapt policies to meet the 15-day requirement, which may have fiscal and programmatic implications for these states.
For more information on the State Innovation Models (SIM) initiative, see: https://innovation.cms.gov/initiatives/state-innovations/.
“Accountable Communities of Health,” CMS, accessed September 5, 2016, https://innovation.cms.gov/initiatives/AHCM.
81 FR 27497, available at: https://www.gpo.gov/fdsys/granule/FR-2016-05-06/2016-09581.
“Medicaid and CHIP Managed Care Final Rule (CMS 2390-F) Implementation Dates,” CMS, April 25, 2016, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/managed-care/downloads/implementation-dates.pdf.
Hawaii, North Dakota and Tennessee auto-assign all new members to a health plan. Hawaii and Tennessee then offer beneficiaries a choice, while North Dakota has only one plan.
Consumer Assessment of Healthcare Providers and Systems survey (CAHPS) was developed by the Agency for Health Research and Quality (AHRQ), http://www.ahrq.gov/cahps/about-cahps/index.html.
California notes that the delivery of substance abuse services is moving to an “Organized Delivery System operated by counties” in FY 2016. For purposes of this report, this new arrangement is treated as a PHP as it is recognized at the federal level.
Emerging Delivery System and Payment Reforms
“Patient-Centered Medical Home Recognition,” National Committee on Quality Assurance, accessed October 1, 2015, http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx.
Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concept (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/.
Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concept (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/.
Ibid.
Massachusetts Executive Office of Health and Human Services, Office of Medicaid, Section 1115 Demonstration Project Amendment and Extension Request (Massachusetts Executive Office of Health and Human Services, Office of Medicaid, July 22, 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-pa.pdf.
Oregon also reported having “DSRIP-like” quality incentive programs in place in FY 2015.
Massachusetts Executive Office of Health and Human Services, Office of Medicaid, Delivery System Transformation Initiatives Trust Fund Legislative Report (Massachusetts Executive Office of Health and Human Services, Office of Medicaid, March 16, 2016), http://www.mass.gov/eohhs/docs/masshealth/research/legislature-reports/dsti-delivery-system-transformation-initiatives-status-report-03-16-16.pdf.
Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model. It is a five-year model that will begin in January 2017. Other states that include Medicaid as a partner but were not reported on this survey include: AR, CO, MT, RI, and TN. For more information see: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus.
Long-Term Services and Supports Reforms
Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2014: Managed LTSS Reached 15 Percent of LTSS Spending (Baltimore, MD: CMS, April 15, 2016) https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf.
Ibid.
The “Program of all All-Inclusive Care for the Elderly” (PACE) is a capitated managed care benefit for frail seniors age 55 and older 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.
There are 11 states with no Section 1915(c) waivers for some or all populations (using Section 1115 instead): AZ, CA, DE, HI, NJ, NM, NY, RI, TN, TX, VT. See: MaryBeth Musumeci, Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2014), https://www.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/.
CMCS Informational Bulletin, Coverage of Housing-Related Activities and Services for Individuals with Disabilities (Baltimore, MD: CMCS, June 26, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-26-2015.pdf.
Molly O'Malley Watts, Erica L. Reaves, and MaryBeth Musumeci, Money Follows the Person: A 2015 State Survey of Transitions, Services, and Costs (Washington, DC: Kaiser Commission on Medicaid and the Uninsured), https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.
“Money Follows the Person (MFP),” CMS, accessed September 23, 2016, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Balancing/Money-Follows-the-Person.html.
CMS issued approval of the core facets of the Washington’s proposal on September 30, 2016 as they work with the state to finalize special terms and conditions (STC)s.
HCBS benefit expansions reported in this section may include new HCBS waiver or SPA initiatives which may have also been reported/counted as expansions in persons served under HCBS through waivers or SPAs.
This count does not include two states (Colorado and Washington) that have managed FFS FADs. For more information see: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/ManagedFeeforServiceModel.html.
The Affordable Care Act (ACA) authorized the Secretary of Health and Human Services to implement the Financial Alignment Initiative to allow state-administered demonstration projects to improve the integration and coordination of services for individuals who are covered under both Medicare and Medicaid. This population, as a group, experiences high rates of hospitalization and use of LTSS and is, on average, a high need, high cost population. See: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.html..
Kaiser Commission on Medicaid and the Uninsured, Health Plan Enrollment in the Capitated Financial Alignment Demonstrations for Dual Eligible Beneficiaries (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, August 2016), https://www.kff.org/medicaid/fact-sheet/health-plan-enrollment-in-the-capitated-financial-alignment-demonstrations-for-dual-eligible-beneficiaries/.
Dual Eligible Special Needs Plans (D-SNPs) enroll beneficiaries who are entitled to both Medicare and Medicaid, and offer the opportunity to better coordinate benefits among Medicare and Medicaid. For more information see: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/DualEligibleSNP.html.
Chronic Condition Special Needs Plans must offer specially-designed plan benefit packages that provide supplemental health benefits and specialized provider networks specific to designated chronic conditions. For more information see: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/Chronic-Condition-Special-Need-Plans-C-SNP.html.
Fully Integrated Dual Eligible SNPs were created by Congress in Section 3205 of the Affordable Care Act to promote full integration and coordination of Medicaid and Medicare benefits for dual eligible beneficiaries by a single managed care organization. They must have a MIPPA compliant contract with a State Medicaid Agency that includes coverage of specified primary, acute and long-term care benefits and services under risk-based financing. For more information see: https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/DualEligibleSNP.html#s3.
“Home and Community-Based Services Quality,” National Quality Forum, accessed September 21, 2016, http://www.qualityforum.org/ProjectDescription.aspx?projectID=77692.
National Quality Forum, Quality in Home and Community-Based Services to Support Community Living: Addressing Gaps in Performance Measurement (Washington, DC: National Quality Forum, September 2016), http://www.qualityforum.org/Publications/2016/09/Quality_in_Home_and_Community-Based_Services_to_Support_Community_Living__Addressing_Gaps_in_Performance_Measurement.aspx.
Provider Rates and Taxes
Rates for calendar 2017 not yet determined at the time of the survey included MCO rates for Florida, Illinois, Maryland, and Minnesota. While some states with calendar year contracts provided the budgeted level of MCO rate increases, these four states indicate that they are waiting for work by their actuaries. Wisconsin is implementing APR-DRGs in in January 2017 which potentially could move funds between inpatient and outpatient hospital rates.
Some states also have premium or claims taxes that apply to managed care organizations and other insurers. Since this type of tax is not considered a provider tax by CMS, these taxes are not counted as provider taxes in this report.
Benefits and Pharmacy
Centers for Medicare and Medicaid Services, CMCS Informational Bulletin: Clarification of Medicaid Coverage of Services to Children with Autism (Washington, DC: Centers for Medicare and Medicaid Services, July 2014), http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-07-14.pdf.
Centers for Medicare and Medicaid Services, Medicaid Drug Rebate Program Notice, Release No. 172 (Centers for Medicare and Medicaid Services, November 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-Drugs/Downloads/Rx-Releases/State-Releases/state-rel-172.pdf.
Interferon-free Direct Acting Antivirals (DAAs) used to treat hepatitis C entered the market in 2013. They have very high cure rates and minimal side-effects, but have been priced expensively.
B.E. and A.R. v. Teeter, No. C16-227-JCC (W.D. Wa. May 27, 2016), https://today.law.harvard.edu/wpcontent/uploads/2016/06/40-5-27-16-Order-Granting-Preliminary-Injunction.pdf.
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.
81 Fed. Reg. 5170.
Centers for Medicare and Medicaid Services, CMCS Informational Bulletin: Medicaid Pharmacy – Survey of Retail Prices (Washington, DC: Centers for Medicare and Medicaid Services, May 2012), http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-05-31-12.pdf.
“Clinical edits” are clinically-based claims adjudication rules that a claims system will follow when processing a pharmacy claim.
Li Hui Chen, Holly Hedegaard, and Margaret Warner, Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011, (National Center for Health Statistics, no. 166, September 2014), http://www.cdc.gov/nchs/products/databriefs/db166.htm
Centers for Medicare and Medicaid Services, CMCS Informational Bulletin: Best Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction, (Baltimore, MD: Centers for Medicare and Medicaid Services, January 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-02-02-16.pdf.
Deborah Dowell, Tamara Haegerich, and Roger Chou, “CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, 65, no.1 (March 2016): 1-49, http://dx.doi.org/10.15585/mmwr.rr6501e1.
National Safety Council, Prescription Nation 2016, Addressing America’s Drug Epidemic (National Safety Council, 2016), http://www.nsc.org/RxDrugOverdoseDocuments/Prescription-Nation-2016-American-Drug-Epidemic.pdf.
Centers for Medicare and Medicaid Services, CMCS Informational Bulletin: Best Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction, (Baltimore, MD: Centers for Medicare and Medicaid Services, January 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-02-02-16.pdf.
Several states mentioned plans to implement quantity limits based on a “morphine equivalent dose” which is the amount of opioid prescription drugs, converted to a common “standard” unit (milligrams of morphine). For example, both 60 mg of oxycodone (approximately 2 tablets of oxycodone sustained-release 30 mg) and approximately 20 mg of methadone (4 tablets of methadone 5 mg) are equal to 90 MMEs (morphine milligram equivalents).
Prescription Drug Monitoring Program Training and Technical Assistance Center, Status of Prescription Drug Monitoring Programs (PDMPs), (Prescription Drug Monitoring Program Training and Technical Assistance Center, August 2015), http://www.pdmpassist.org/pdf/PDMPProgramStatus2015_v5.pdf.
Several states with requirements noted that they were statutory (rather than contractual) including two states (Arizona and Maryland) reporting a legislative requirement that would take effect in FY 2018. One state commented that its Medicaid agency did not have access to the PDMP and therefore was unable to mandate its use by Medicaid prescribers.
Methods
State fiscal years begin July 1 except for these states: NY on April 1; TX on September 1; AL, MI and DC on October 1.
Also of Interest
- The 16th Annual Kaiser 50-State Medicaid Budget Survey: Slowing Growth and Evolving Policies at a Forum with the National Association of Medicaid Directors
- Medicaid Enrollment & Spending Growth: FY 2016 & 2017
- Putting Medicaid in the Larger Budget Context: An In-Depth Look at Four States in FY 2016 and FY 2017
- 50-State Medicaid Budget Survey Archives