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Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018

Executive Summary
  1. Medicaid work requirement proposals generally require beneficiaries to verify their participation in approved activities, such as employment, job search, or job training programs, for a certain number of hours per week to receive health coverage. The proposals typically would exempt certain populations. To date, CMS has not approved state waiver requests to require that Medicaid beneficiaries work as a condition of eligibility.

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  2. While still maintaining the enhanced federal matching rate for coverage of the remaining expansion population at or below 100% FPL.

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  3. Six states (CA, MA, MD, VA, VT, and WV) currently have received federal approval through Section 1115 waiver authority to waive the IMD payment exclusion to receive federal Medicaid funds for inpatient behavioral health services for nonelderly adults. Nine states (AZ, IL, IN, KY, MA, MI, NJ, WI, and UT) currently have pending Section 1115 waivers at CMS which seek to waive the IMD payment exclusion.

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  4. AR and IL did not respond to the MAT drug coverage question; however, a Health Affairs article (citation below) that uses 2013-2014 data indicates that all 51 states cover buprenorphine.

    Colleen Grogan et al., “Survey Highlights Differences in Medicaid Coverage for Substance Use Treatment and Opioid Use Disorder Medications,” Health Affairs 35 no. 12 (December 2016): 2289-2296, http://content.healthaffairs.org/content/35/12/2289.

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Introduction
  1. Centers for Medicare & Medicaid Services. National Health Expenditures (Washington, DC: Centers for Medicare & Medicaid Services, December 2016), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.

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  2. 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.

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  3. Kaiser Family Foundation, 50-State Medicaid Budget Survey Archives, (Washington, DC: Kaiser Family Foundation, October 2017), https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.

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Eligibility and Premiums
  1. While still maintaining the enhanced federal matching rate for coverage of the remaining expansion population at or below 100% FPL.

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  2. Legislators dropped their lawsuit challenging Governor Cooper’s authority to expand Medicaid without legislative approval in July 2017 because Cooper never formally submitted his expansion proposal to the federal government for review. However, in a joint statement, the State Senate President and Speaker of the State House said that they would renew a legal challenge if the Governor made another attempt to expand without lawmakers' approval.

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  3. Maine Question 2, Medicaid Expansion Initiative, (Ballotpedia, 2017), https://ballotpedia.org/Maine_Question_2,_Medicaid_Expansion_Initiative_(2017).

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  4. Individuals eligible for the Family Planning Waiver included women ages 18 through 55 who have family income at or below 185 percent of the federal poverty level (FPL) and assets totaling less than $250,000, and who are not otherwise eligible for Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or health insurance coverage that provides family planning services.

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  5. Missouri has replaced its family planning waiver with a state-funded family planning coverage program that does not cover or pay for services provided by organizations that also provide abortion services, including Planned Parenthood. Women who are eligible for the federally-funded program will continue to be eligible for the state-funded program, without change. The available services remain the same but the provider qualifications are modified.

    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.

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  6. Thomas Price and Seema Verma letter to governors, March 14, 2017, https://www.hhs.gov/sites/default/files/sec-price-admin-verma-ltr.pdf.

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  7. Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, and Larisa Antonisse, Section 1115 Medicaid Demonstration Waivers: A look at the Current Landscape of Approved and Pending Waivers, (Washington, DC: Kaiser Family Foundation, September 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-a-look-at-the-current-landscape-of-approved-and-pending-waivers/.

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  8. States with pending waiver proposals with provisions slated for implementation after FY 2018 include Alaska, Colorado, Illinois, Indiana, Kentucky, Maine, Massachusetts, New Mexico, North Carolina, Oklahoma, Virginia, and Wisconsin.

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  9. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions (Washington, DC: Kaiser Family Foundation, August 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-and-state-specific-waiver-provisions/.

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  10. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions (Washington, DC: Kaiser Family Foundation, August 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-and-state-specific-waiver-provisions/.

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  11. CMS’s waiver of retroactive eligibility in Arkansas is conditioned on the state completing an eligibility determination mitigation plan, making timely eligibility determinations, providing benefits during a reasonable opportunity period for otherwise eligible individuals who attest to immigration status, and implementing a hospital presumptive eligibility program.

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  12. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions (Washington, DC: Kaiser Family Foundation, August 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-and-state-specific-waiver-provisions/.

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  13. The member can reenroll within 90 days from the end of the expired benefit period if they submit the requested redetermination information. However, after the 90-day period, the member is required to wait another three months, or six months from the initial date of disenrollment, until their next open enrollment before being permitted to reenroll in HIP. Indiana has also proposed a work requirement, but that provision would not be effective until FY 2019.

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  14. As of the date of publication, the state’s waiver amendment was still pending approval at CMS.

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  15. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin (Washington, DC: Kaiser Family Foundation, updated August 2017), https://www.kff.org/medicaid/issue-brief/proposed-medicaid-section-1115-waivers-in-maine-and-wisconsin/.

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  16. The full waiver application is available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/me/me-mainecare-pa.pdf , and a summary of its provisions is available at https://www.kff.org/medicaid/issue-brief/proposed-medicaid-section-1115-waivers-in-maine-and-wisconsin/.

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  17. Enrollment in the PCN limited benefit package for adults up to 100% FPL is capped at 25,000.

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  18. Although these policies are similar to policies in other states that are counted as eligibility restrictions in this report, they are not counted as eligibility restrictions in Utah because they apply only to the new childless adult group that does not currently have access to coverage.

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  19. Maine’s pending Section 1115 waiver proposes requiring monthly premiums for traditional adults (such as parents, former foster care youth, those receiving TMA, medically needy, those receiving family planning services). While the waiver proposal’s estimated implementation date for most other (non-premium) provisions is January 1, 2018, the state doesn’t plan to implement the premium provisions until six months later (estimated at July 1, 2018). Given this FY 2019 anticipated implementation date, Maine’s premium proposal is not counted in this section of the report (which captures premium changes in FY 2017 and planned for FY 2018).

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  20. Jennifer Ryan, Lucy Pagel, Katy Smali, Samantha Artiga, Robin Rudowitz, and Alexandra Gates, Connecting the Justice-Involved Population to Medicaid Coverage and Care: Findings from Three States (Washington, DC, Kaiser Commission on Medicaid and the Uninsured, June 2016), https://www.kff.org/medicaid/issue-brief/connecting-the-justice-involved-population-to-medicaid-coverage-and-care-findings-from-three-states/.

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  21. Some states suspend by limiting covered benefits to inpatient hospitalization.

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  22. Positive changes from the beneficiary’s perspective that were counted in this report are denoted with (+). Negative changes from the beneficiary’s perspective that were counted in this report are denoted with (-). Reductions to Medicaid eligibility pathways in response to the availability of other coverage options (including Marketplace or Medicaid expansion coverage) were denoted as (#).

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  23. New premiums are denoted as (New). Changes to premium policies that have a neutral impact from the beneficiary’s perspective are denoted as (Neutral).

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  24. This table captures eligibility and premium changes that states have implemented or plan to implement in FY 2017 or 2018, including changes that are part of pending Section 1115 waivers. For pending waivers, only provisions planned for implementation before the end of FY 2018 (according to waiver application documents) are counted in this table. Waiver provisions in pending waivers that states plan to implement in FY 2019 or after are not counted here.

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  25. CMS’s waiver of retroactive eligibility in Arkansas is conditioned on the state completing an eligibility determination mitigation plan, making timely eligibility determinations, providing benefits during a reasonable opportunity period for otherwise eligible individuals who attest to immigration status, and implementing a hospital presumptive eligibility program.

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  26. Massachusetts’ pending amendment would remove an existing waiver provision that allows it to enroll expansion adults and other populations in coverage during a 90-day provisional eligibility period while income verification is pending.

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Managed Care Initiatives
  1. Six states (CA, MA, MD, VA, VT, and WV) currently have received federal approval through Section 1115 waiver authority to waive the IMD payment exclusion to receive federal Medicaid funds for inpatient behavioral health services for nonelderly adults. Nine states (AZ, IL, IN, KY, MA, MI, NJ, WI, and UT) currently have pending Section 1115 waivers at CMS which seek to waive the IMD payment exclusion.

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  2. Julia Paradise and MaryBeth Musumeci, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (Washington, DC: Kaiser Family Foundation, June 2016), http://files.kff.org/attachment/CMSs-Final-Rule-on-Medicaid-Managed-Care.

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  3. The general effective date of the final rule is July 5, 2016, although individual provisions of the rule take effect at different times.

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  4. Brian Neale, Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates, (Center for Medicaid and CHIP Services Informational Bulletin, June 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf.

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  5. 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.

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  6. 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.

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  7. Centers for Medicare and Medicaid Services, Medicaid & CHIP Monthly Application, Eligibility Determinations, and Enrollment Reports, (Washington, DC: Centers for Medicare and Medicaid Services, May 2017), 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.

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  8. Arizona was re-characterized from “Varies” to “Always Mandatory” across all population groups as the only non-mandatory group is Native Americans in compliance with federal requirements.

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  9. 81 FR 27497, available at: https://www.gpo.gov/fdsys/granule/FR-2016-05-06/2016-09581.

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  10. 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.

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  11. Six states (CA, MA, MD, VA, VT, and WV) currently have received federal approval through Section 1115 waiver authority to waive the IMD payment exclusion to receive federal Medicaid funds for inpatient behavioral health services for nonelderly adults. Nine states (AZ, IL, IN, KY, MA, MI, NJ, WI, and UT) currently have pending Section 1115 waivers at CMS which seek to waive the IMD payment exclusion.

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  12. National Association of Medicaid Directors, Medicaid Value-Based Purchasing: What Is It & Why Does It Matter? (Washington, DC: National Association of Medicaid Directors, January 2017), http://medicaiddirectors.org/wp-content/uploads/2017/01/Snapshot-2-VBP-101_FINAL.pdf.

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  13. For more information on the State Innovation Models (SIM) initiative, see: https://innovation.cms.gov/initiatives/state-innovations/.

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  14. Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program: http://www.dhcs.ca.gov/provgovpart/Pages/PRIME.aspx.

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  15. Centers for Medicare and Medicaid Services, CMS’ Accountable Health Communities Model selects 32 participants to serve as local “hubs”, (Baltimore, MD: Centers for Medicare and Medicaid Services, April 2017), https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-04-06.html.

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  16. Centers for Medicare and Medicaid Services, Medicaid and CHIP Managed Care Final Rule (CMS 2390-F) Implementation Dates (Baltimore, MD: Centers for Medicare and Medicaid Services, April 2017), https://www.medicaid.gov/medicaid/managed-care/downloads/implementation-dates.pdf.

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  17. Remittances are required for the expansion population in Ohio.

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  18. Texas reported ending its Texas Medicaid Wellness Program in August 2017. This care management program was not counted as a PCCM program for purposes of this report although it operated under PCCM authority.

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  19. One of the 25 states reporting a PHP arrangement that is not included in Exhibit 5 is Alabama, which reported having a PHP for maternity care.

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Emerging Delivery System and Payment Reforms
  1. “Patient-Centered Medical Home Recognition,” National Committee on Quality Assurance, accessed October 1, 2015, http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx.

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  2. 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), http://kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/.

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  3. In this report, Oregon’s Coordinated Care Organization (CCO) program is counted as an MCO program, but not as an ACO program, consistent with its CMS designation and the state’s survey response. According to the state, “A coordinated care organization is a network of all types of health care providers (physical health care, addictions and mental health care and sometimes dental care providers) who have agreed to work together in their local communities to serve people who receive health care coverage under the Oregon Health Plan (Medicaid).” (Oregon Health Authority website accessed at: http://www.oregon.gov/oha/HPA/Pages/CCOs-Oregon.aspx.)

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  4. 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), http://kff.org/medicaid/fact-sheet/medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts/.

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  5. Samantha Artiga, Robin Rudowitz, Jennifer Tolbert, Julia Paradise, and Melissa Majerol, Findings from the Field: Medicaid Delivery Systems and Access to Care in Four States in Year Three of the ACA (Washington, DC, Kaiser Commission on Medicaid and the Uninsured, September 2016), https://www.kff.org/report-section/findings-from-the-field-medicaid-delivery-systems-and-access-to-care-in-four-states-in-year-three-of-the-aca-issue-brief/.

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  6. Rhode Island Executive Office of Health and Human Services (EOHHS), Medicaid Program Accountable Entity Roadmap Document (EOHHS, April 2017), accessed at: http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/Acc_Entitites/MedicaidAERoadmap.pdf.

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  7. Alexandra Gates, Robin Rudowitz, and Jocelyn Guyer, An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers (Washington, DC, Kaiser Commission on Medicaid and the Uninsured, September 2014), https://www.kff.org/report-section/findings-from-the-field-medicaid-delivery-systems-and-access-to-care-in-four-states-in-year-three-of-the-aca-issue-brief/.

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  8. Originally, DSRIP initiatives were more narrowly focused on funding for safety net hospitals and often grew out of negotiations between states and HHS over the appropriate way to finance hospital care.

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  9. Gobeille v. Liberty Mutual Insurance Company, No. 14-181, 577 U.S. ___ (2016). In this case, the Supreme Court of the United States held that the Employee Retirement Income Security Act (ERISA) pre-empts a Vermont law that requires certain entities, including health insurers, to report payments relating to health care claims and other information relating to health care services to a state agency for compilation in an all-inclusive health care database.

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  10. Elizabeth Hinton and Julia Paradise, Access to Dental Care in Medicaid: Spotlight on Nonelderly Adults, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, May 2016), https://www.kff.org/medicaid/issue-brief/access-to-dental-care-in-medicaid-spotlight-on-nonelderly-adults/.

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  11. Medicare Payment Advisory Commission, “Telehealth Services and the Medicare Program,” chap. 8 in Report to the Congress: Medicare and the Health Care Delivery System, (Washington, DC: June 2016), 229-260, http://www.medpac.gov/docs/default-source/reports/chapter-8-telehealth-services-and-the-medicare-program-june-2016-report-.pdf?sfvrsn=0.

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Long-Term Services and Supports Reforms
  1. Vikki Wachino, Coverage of Housing-Related Activities and Services for Individuals with Disabilities (Baltimore, MD: Center for Medicaid and CHIP Services Informational Bulletin, June 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-26-2015.pdf.

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  2. Steve Eiken, Kate Sredl, Brian Burwell, and Rebecca Woodward, Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2015 (Baltimore, MD: CMS, April 2017), https://www.medicaid.gov/medicaid/ltss/downloads/reports-and-evaluations/ltssexpendituresffy2015final.pdf.

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  3. 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/ltss/downloads/ltss-expenditures-2014.pdf.

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  4. Serving more individuals through “HCBS Waivers or SPAs” means: adopting new waiver; adding and filling more waiver slots; filling more waiver slots; adding new 1915(i) or 1915(k) SPA; or serving more individuals through existing 1915(i) or 1915(k) SPA.

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  5. While various Medicaid state plan authorities enable states to expand beneficiary access to home and community-based services (HCBS), some states are using Section 1115 waivers to streamline program administration, improve care coordination, and expand beneficiary access to home and community-based services (HCBS).

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  6. Of 23 states with MLTSS.

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  7. “Serving more people through PACE” means: adding new provider sites and/or increasing the number of people served at existing sites.

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  8. CMCS Informational Bulletin, Coverage of Housing-Related Activities and Services for Individuals with Disabilities (Baltimore, MD: Center for Medicaid and CHIP Services, June 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-26-2015.pdf.

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  9. After September 2016, with CMS approval, states can continue to transition eligible individuals through 2018 and expend remaining MFP funds through federal FY 2020.

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  10. Oregon is not included in this count. The state terminated its MFP program, effective June 30, 2015.

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  11. CMS provides information on Money Follows the Person at https://www.medicaid.gov/medicaid/ltss/money-follows-the-person/index.html.

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  12. Molly O'Malley Watts, Erica Reaves, and MaryBeth Musumeci, Money Follows the Person: A 2015 State Survey of Transitions, Services, and Costs, (Washington, DC: Kaiser Family Foundation, October 2015), https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.

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  13. Most of these states are using current Section 1915(c) waivers that provide community transition services and environmental modifications for seniors, individuals with physical disabilities and/or individuals with intellectual or developmental disabilities, and some states offer housing coordinators or other search services to assist waiver beneficiaries.

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  14. “Money Follows the Person (MFP),” Centers for Medicare and Medicaid Services, accessed October 1, 2017, https://www.medicaid.gov/medicaid/ltss/money-follows-the-person/index.html.

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  15. Molly O’Malley Watts, MaryBeth Musumeci, and Petry Ubri, Medicaid Section 1115 Managed Long-Term Services and Supports Waivers: A Survey of Enrollment, Spending an Program Policies, (Washington, DC: Kaiser Family Foundation, January 2017), https://www.kff.org/medicaid/report/medicaid-section-1115-managed-long-term-services-and-supports-waivers-a-survey-of-enrollment-spending-and-program-policies/.

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  16. U.S. Senate Commission on Long-Term Care, Report to the Congress, (U.S. Senate Commission on Long-Term Care, September 2013), https://www.gpo.gov/fdsys/pkg/GPO-LTCCOMMISSION/pdf/GPO-LTCCOMMISSION.pdf.

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  17. Arkansas, Delaware, and Minnesota noted they are/will be forming work/advisory groups to study the issue further. New York also reported an expanded scope of practice for home care aides. North Carolina reported consumer-directed care is included as an option in the newly approved children's waiver. North Dakota reported ongoing efforts to address LTSS direct care workforce through its MFP program. Texas reported working with external and internal stakeholders to develop measures and methods to monitor access to MLTSS as it relates to managed care organization network adequacy.

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  18. 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.

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  19. 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.

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  20. Rhode Island and South Carolina launched the FAD in FY 2017.

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  21. 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..

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  22. 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), http://kff.org/medicaid/fact-sheet/health-plan-enrollment-in-the-capitated-financial-alignment-demonstrations-for-dual-eligible-beneficiaries/.

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  23. Arizona, Hawaii, Massachusetts, New Mexico, Pennsylvania, Tennessee, Texas, and Virginia. (Virginia has FAD model that the state plans to terminate by the end of 2017. Virginia is also launching MLTSS program in August 2017.)

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  24. 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.

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  25. 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.

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  26. Delaware, Iowa, Idaho, Minnesota, and New Jersey.

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Provider Rates and Taxes
  1. Rates for calendar year 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 could potentially move funds between inpatient and outpatient hospital rates.

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  2. Historically, Medicaid reimbursement for hospitals and nursing homes was cost-based, automatically reflecting incurred cost increases. When rates for these providers are frozen, such annual increases do not occur; hence for this report, rate freezes are counted as restrictions.

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  3. 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.

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  4. In addition to the “Medicaid provider taxes” included in this report, several states have more general health care taxes that are used to fund their Medicaid programs. For instance, some states have taxes on insurance premiums or health care claims that apply to all payers. States were asked whether they have a tax on MCOs, health insurance premiums, or health care claims that does not apply to other goods and services. Thirteen states that had not indicated a Medicaid MCO provider tax replied “yes”. Two of these states indicated that all of the health insurance tax is dedicated to Medicaid. Four indicated that it was dedicated to Medicaid in part.

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  5. Kaiser Family Foundation, Compare Proposals to Replace the Affordable Care Act, (Washington, DC: Kaiser Family Foundation, September 2017), https://www.kff.org/interactive/proposals-to-replace-the-affordable-care-act/.

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  6. Robin Rudowitz, Larisa Antonisse, and MaryBeth Musumeci, Medicaid Changes in Better Care Reconciliation Act (BCRA) Go Beyond ACA Repeal and Replace, (Washington, DC: Kaiser Family Foundation, July 2017), https://www.kff.org/medicaid/issue-brief/medicaid-changes-in-better-care-reconciliation-act-bcra-go-beyond-aca-repeal-and-replace/.

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  7. Kaiser Family Foundation, Summary of Graham-Cassidy-Heller-Johnson Amendment, (Washington, DC: Kaiser Family Foundation, September 2017), http://files.kff.org/attachment/Summary-of-Graham-Cassidy-Heller-Johnson-Amendment.

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Benefits, Copayments, Pharmacy, and Opioid Strategies
  1. AR and IL did not respond to the MAT drug coverage question; however, a Health Affairs article (citation below) that uses 2013-2014 data indicates that all 51 states cover buprenorphine.

    Colleen Grogan et al., “Survey Highlights Differences in Medicaid Coverage for Substance Use Treatment and Opioid Use Disorder Medications,” Health Affairs 35 no. 12 (December 2016): 2289-2296, http://content.healthaffairs.org/content/35/12/2289.

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  2. Centers for Medicare and Medicaid Services, New Service Delivery Opportunities for Individuals with a Substance Use Disorder (Baltimore, MD: CMS, July 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf.

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  3. BRCA1 and BRCA2 are human genes that produce tumor suppressor proteins that help repair damaged DNA and play a role in ensuring the stability of the cell’s genetic material. When either of these genes are mutated or altered, cells are more likely to develop additional genetic alterations that can lead to cancer. Specific inherited mutations in BRCA1 and BRCA2 increase the risk of female breast and ovarian cancers. More information is available from the National Cancer Institute: https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet.

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  4. Utah proposes covering a new eligibility group: individuals with income below 5 percent of the FPL who are either chronically homeless, justice-involved, or individuals in need of substance use and/or mental health treatment. This EPSDT restriction would apply to 19 and 20 year olds in this group.

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  5. Julia Paradise, Medicaid Moving Forward (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2015), http://kff.org/health-reform/issue-brief/medicaid-moving-forward/.

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  6. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin (Washington, DC: Kaiser Family Foundation, updated August 2017), https://www.kff.org/medicaid/issue-brief/proposed-medicaid-section-1115-waivers-in-maine-and-wisconsin/.

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  7. Positive changes counted in this report are denoted with (+). Negative changes counted in this report are denoted with (-). Changes that were not counted as positive or negative in this report, but were mentioned by states in their responses, are denoted with (nc). Federally required changes are also denoted with (nc).

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  8. New copayments as well as new requirements such as making copayments enforceable are denoted as (New). Increases in existing copayments are denoted as (Increase), while decreases are denoted as (Decrease), neutral changes from the beneficiary’s perspective are denoted as (Neutral), and eliminations are denoted as (Elimination

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  9. Katherine Young, Robin Rudowitz, Rachel Garfield, and MaryBeth Musumeci, Medicaid’s Most Costly Outpatient Drugs (Washington, DC: Kaiser Family Foundation, July 2016), https://www.kff.org/medicaid/issue-brief/medicaids-most-costly-outpatient-drugs/.

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  10. 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.

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  11. 81 Fed. Reg. 5170.

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  12. 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.

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  13. One of the states that projected greater costs (South Carolina) reported, however, that it is negotiating with CMS to retain its current reimbursement methodology and not move to AAC and a professional dispensing fee. The state’s interpretation of the rule is that it sets an aggregate cost cap based on the AAC methodology but does not require adoption of this methodology. South Carolina believes it is compliant with the rule as its pharmacy expenditures are within the aggregate cap based on AAC, but if the state were to adopt the AAC methodology, it would incur greater costs.

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  14. Wisconsin Department of Health Services, Family Care, Family Care Partnership, and PACE Enrollment Data, (Wisconsin Department of Health Services, August 2017), https://www.dhs.wisconsin.gov/familycare/reports/enrollmentdata.pdf.

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  15. A “kick payment” is a supplemental payment over and above the capitation payment made to an MCO for beneficiaries utilizing a specified set of services or having a certain condition.

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  16. “Understanding the Epidemic,” Centers for Disease Control and Prevention, accessed on October 1, 2017, https://www.cdc.gov/drugoverdose/epidemic/index.html.

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  17. Li Hui Chen, Holly Hedegaard, and Margaret Warner, “Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011,” National Center for Health Statistics data brief, no 166 (September 2014), https://www.cdc.gov/nchs/data/databriefs/db166.pdf.

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  18. Katherine Young and Julia Zur, Medicaid and the Opioid Epidemic: Enrollment, Spending, and the Implications of Proposed Policy Changes (Washington, DC: The Kaiser Family Foundation, July 2017), https://www.kff.org/medicaid/issue-brief/medicaid-and-the-opioid-epidemic-enrollment-spending-and-the-implications-of-proposed-policy-changes/.

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  19. Center for Medicaid and CHIP Services, Best Practices for Addressing Prescription Opioid Overdoses, Misuse, and Addiction, (Baltimore, MD: CMCS Informational Bulletin, January 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/cib-02-02-16.pdf.

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  20. 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.

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  21. Center for Medicaid and CHIP Services, Best Practices for Addressing Prescription Opioid Overdoses, Misuse, and Addiction, (Baltimore, MD: CMCS Informational Bulletin, January 2016), https://www.medicaid.gov/federal-policy-guidance/downloads/cib-02-02-16.pdf.

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  22. Several states mentioned plans to implement quantity limits based on a “morphine equivalent dose” (MED), 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).

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  23. “Clinical edits” are clinically-based claims adjudication rules that a claims system will follow when processing a pharmacy claim.

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  24. Step therapy prior authorization criteria involves requiring the use of another agent prior to the use of a specific opioid.

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  25. Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases that are valuable tools for addressing prescription drug diversion and abuse. Currently, except for Missouri, every state and the District of Columbia operates a PDMP. On July 17, 2017, however, Missouri Governor Eric Greitens issued an Executive Order directing the Missouri Department of Health and Senior Services (DHSS) to implement a PDMP and promulgate regulations to require dispensers to submit controlled substance prescription and dispensation information to DHSS or its designee.

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  26. Lock-in programs limit Medicaid beneficiaries to a specific pharmacy and/or prescriber. These programs are intended to prevent Medicaid beneficiaries from obtaining excessive quantities of prescribed drugs through visits to multiple physicians and pharmacies.

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  27. “Opioid Overdose Reversal with Naloxone (Narcan, Evzio),” National Institute on Drug Abuse, revised September 2016, https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio.

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  28. Ravi Gupta, Nilay Shah, and Joseph Ross, “The Rising Price of Naloxone – Risks to Efforts to Stem Overdose Deaths,” New England Journal of Medicine, 375 (December 2016): 2213-2215, http://www.nejm.org/doi/full/10.1056/NEJMp1609578#t=article.

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  29. “Medication-Assisted Treatment (MAT),” Substance Abuse and Mental Health Services Administration, November 2016, https://www.samhsa.gov/medication-assisted-treatment.

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  30. The Pew Charitable Trusts, Medication-Assisted Treatment Improves Outcomes for Patients With Opioid Use Disorder, (Washington, DC: The Pew Charitable Trusts, November 2016), http://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2016/11/medication-assisted-treatment-improves-outcomes-for-patients-with-opioid-use-disorder.

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  31. Colleen Grogan et al., “Survey Highlights Differences in Medicaid Coverage for Substance Use Treatment and Opioid Use Disorder Medications,” Health Affairs 35 no. 12 (December 2016): 2289-2296, http://content.healthaffairs.org/content/35/12/2289.

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  32. AR and IL did not respond to the MAT drug coverage question; however, a Health Affairs article (citation below) that uses 2013-2014 data indicates that all 51 states cover buprenorphine.

    Colleen Grogan et al., “Survey Highlights Differences in Medicaid Coverage for Substance Use Treatment and Opioid Use Disorder Medications,” Health Affairs 35 no. 12 (December 2016): 2289-2296, http://content.healthaffairs.org/content/35/12/2289.

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Administrative Challenges, Priorities, and Conclusion
  1. National Association of Medicaid Directors, NAMD Statement on Graham-Cassidy, (Washington, DC: NAMD Press Release, September 2017), http://medicaiddirectors.org/category/press-release/.

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  2. Thomas Price and Seema Verma letter to governors, March 14, 2017, https://www.hhs.gov/sites/default/files/sec-price-admin-verma-ltr.pdf.

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  3. Medicaid work requirement proposals generally require beneficiaries to verify their participation in approved activities, such as employment, job search, or job training programs, for a certain number of hours per week to receive health coverage. The proposals typically would exempt certain populations. To date, CMS has not approved state waiver requests to require that Medicaid beneficiaries work as a condition of eligibility.

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  4. Implementation dates for Section 1115 waiver provisions included/cited in this report are the dates proposed in state waiver applications submitted to CMS.

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  5. Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, and Larisa Antonisse, Section 1115 Medicaid Demonstration Waivers: A look at the Current Landscape of Approved and Pending Waivers, (Washington, DC: Kaiser Family Foundation, September 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-a-look-at-the-current-landscape-of-approved-and-pending-waivers/.

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  6. Kaiser Family Foundation, Proposed Changes to Medicaid Expansion in Kentucky (Washington, DC: Kaiser Family Foundation, August 2017), https://www.kff.org/medicaid/fact-sheet/proposed-changes-to-medicaid-expansion-in-kentucky/.

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  7. Beginning at 5 hours/week and increasing to a maximum of 20 hours/week.

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  8. Matthew Bevin, Kentucky Health: Helping to Engage and Achieve Long Term Health, (KY Office of the Governor, August 2016), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ky/ky-health-pa.pdf.

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  9. Commonwealth of Massachusetts Office of Medicaid, MassHealth Section 1115 Demonstration Amendment Request, (Commonwealth of Massachusetts Office of Medicaid, September 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-pa3.pdf.

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  10. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin (Washington, DC: Kaiser Family Foundation, updated August 2017), https://www.kff.org/medicaid/issue-brief/proposed-medicaid-section-1115-waivers-in-maine-and-wisconsin/.

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  11. In 2014, Wisconsin implemented a new Section 1115 waiver covering childless adults ages 19 to 64 with income up to 100% FPL; those above 100% FPL are covered in the Marketplace. (Wisconsin covers childless adults without ACA enhanced matching funds.)

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  12. State proposes to exempt childless adults ages 19 to 49 from the 48 month time limit if working or attending job training 80 hours per month and proposes to use Medicaid funds to offer job training as a covered benefit for childless adults.

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  13. State of Wisconsin Department of Health Services, BadgerCare Reform Demonstration Project: Coverage of Adults Without Dependent Children with Income at or Below 100 Percent of the Federal Poverty Level, Section 1115 Demonstration Waiver. Amendment Application, (State of Wisconsin Department of Health Services, June 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wi/wi-badgercare-reform-pa.pdf.

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  14. Alaska Department of Health and Social Services, Alaska Behavioral Health Reform 1115 Waiver Concept Paper (Alaska Department of Health and Social Services, January 2017), http://dhss.alaska.gov/HealthyAlaska/Documents/Initiatives/1115_ConceptPaper1-5-17wAppendix.pdf.

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  15. New Mexico Human Services Department, Centennial Care 2.0: Section 1115 Demonstration Waiver Renewal Concept Paper, (New Mexico Human Services Department, May 2017), http://www.hsd.state.nm.us/uploads/files/CC%202%200%20Concept%20Paper_FINAL.pdf.

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Methods
  1. Kaiser Family Foundation, 50-State Medicaid Budget Survey Archives, (Washington, DC: Kaiser Family Foundation, October 2017), https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.

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  2. 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.

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