Filling the need for trusted information on national health issues

States Focus on Quality and Outcomes Amid Waiver Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019

Executive Summary
  1. Gene therapy is used to treat or prevent genetic diseases by seeking to augment, replace or suppress one or more mutated genes with functional copies. CAR T-cell therapy is a form of immunotherapy that uses specially altered T cells (part of the immune system) collected from the patient to fight cancer.

    ← Return to text

  2. MaryBeth Musumeci and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/.

    ← Return to text

Introduction
  1. Centers for Medicare and Medicaid Services, National Health Expenditure Projections 2017 – 2026 (Washington, DC: Centers for Medicare and Medicaid Services, February 2018), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html.

    ← Return to text

  2. National Association of State Budget Officers, States Finalize Fiscal 2019 Budgets, (NASBO, July 2018), https://www.nasbo.org/resources/communityblogs.

    ← Return to text

  3. National Conference of State Legislatures, FY 2019 State Budget Status, (NCSL, August 2018), http://www.ncsl.org/research/fiscal-policy/fy-2019-budget-status.aspx.

    ← Return to text

  4. National Association of State Budget Officers, Summary: Fall 2017 Fiscal Survey of the States (National Association of State Budget Officers, December 2017), https://www.nasbo.org/reports-data/fiscal-survey-of-states.

    ← Return to text

  5. National Association of State Budget Officers, States Target Surpluses to Rainy Day Funds, Other Priorities after Fiscal 2018 Revenues Exceed Estimates (National Association of State Budget Officers Budget Blog, July 2018), http://budgetblog.nasbo.org/budgetblogs/blogs/brian-sigritz/2018/07/30/states-target-surpluses-to-rainy-day-funds-other-p.

    ← Return to text

  6. 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/.

    ← Return to text

  7. Responses for North Dakota reflect information gathered during a telephone interview in early September 2018 and related research.

    ← Return to text

  8. 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.

    ← Return to text

Eligibility and Premiums
  1. Brian Neale letter to state Medicaid directors, January 11, 2018, https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf

    ← Return to text

  2. Kaiser Family Foundation, Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? (Washington, DC: Kaiser Family Foundation, accessed September 2018), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-a-look-at-the-current-landscape-of-approved-and-pending-waivers/.

    ← Return to text

  3. In this report, work requirement policies are counted based on the initial date of implementation rather than the date on which the first coverage terminations will occur.

    ← Return to text

  4. Medicaid statute requires that Medicaid coverage for most eligibility groups include coverage for a period of 90 days prior to the date of the application for medical assistance.

    ← Return to text

  5. MaryBeth Musumeci, Elizabeth Hinton, and Robin Rudowitz, Approved Changes in Indiana’s Section 1115 Medicaid Waiver Extension (Washington, DC: Kaiser Family Foundation, February 2018), https://www.kff.org/medicaid/issue-brief/approved-changes-in-indianas-section-1115-medicaid-waiver-extension/.

    ← Return to text

  6. 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.

    ← Return to text

  7. 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/.

    ← Return to text

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

    ← Return to text

  9. Nevada also implemented this option but did so using Children’s Health Insurance Program (CHIP) funds and therefore is not counted in this report.

    ← Return to text

  10. 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/.

    ← Return to text

  11. 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 (#).

    ← Return to text

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

    ← Return to text

  13. This table captures eligibility and premium changes that states have implemented or plan to implement in FY 2018 or 2019, including changes that are part of pending Section 1115 waivers. For pending waivers, only provisions planned for implementation before the end of FY 2019 (according to the state or waiver application documents) are counted in this table. Waiver provisions in pending waivers that states plan to implement in FY 2020 or after are not counted here.

    ← Return to text

  14. A court order issued on June 29, 2018 vacated the CMS approval of the Kentucky HEALTH waiver and remanded it to CMS for reconsideration regarding how the waiver would meet the medical assistance objectives of the Medicaid statute. At the time of the survey, the waiver remained under consideration at CMS.

    ← Return to text

  15. After failing to meet the SPA submission deadline (April 3, 2018), Maine’s Governor complied with a Maine Supreme Judicial Court order to submit an expansion SPA on September 4, 2018. However, he also sent a letter to the federal government asking CMS to reject the SPA. Expansion has not yet been implemented as of the time of this survey.

    ← Return to text

  16. 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.

    ← Return to text

Managed Care Initiatives
  1. 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.

    ← Return to text

  2. California has a small PCCM program operating in LA County for those with HIV. South Carolina uses PCCM authority to provide care management services to approximately 200 medically complex children, but is not counted as a PCCM program for purposes of this report.

    ← Return to text

  3. 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-ManagedCare.

    ← Return to text

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

    ← Return to text

  5. National Association of Medicaid Directors, Biweekly Update, August 14, 2018, available at: https://medicaiddirectors.org/covered-in-this-newsletter-is-cms-drug-rebate-guidance-notice-cbo-report-on-growth-medicaid-managed-care-and-state-job-openings/.

    ← Return to text

  6. 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.

    ← Return to text

  7. North Dakota’s total MCO penetration rate estimated as approximately 22% based on data provided in the North Dakota Department of Human Services Quarterly Budget Insight, July 2017 – June 2018, available at http://www.nd.gov/dhs/info/pubs/docs/qtrly-budget-insight-july17-june2018.pdf.

    ← Return to text

  8. Centers for Medicare and Medicaid Services, Medicaid & CHIP Monthly Application, Eligibility Determinations, and Enrollment Reports, (Washington, DC: Centers for Medicare and Medicaid Services, May 2018), https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html.

    ← Return to text

  9. Illinois reported the MCO penetration rate for all beneficiaries but did not report penetration rates for the individual eligibility categories.

    ← Return to text

  10. The five Medicaid expansion states without risk-based managed care were Alaska, Arkansas, Connecticut, Montana, and Vermont.

    ← Return to text

  11. Two other states (Colorado and Massachusetts) reported covering less than 75% MCO penetration for this group. Illinois reported the MCO penetration rate for all beneficiaries but did not report penetration rates for the individual eligibility categories.

    ← Return to text

  12. 81 FR 27497, available at: https://www.gpo.gov/fdsys/granule/FR-2016-05-06/2016-09581.

    ← Return to text

  13. In the rule, CMS formalized 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.

    ← Return to text

  14. 28 states answered “yes” for FYs 2018 and 2019: AZ, CO, DC, DE, FL, GA, HI, IA, IL, IN, KY, LA, MA, MI, MN, NJ, NM, NV, OH, OR, PA, RI, TN, TX, UT, VA, WA, and WI. 3 states (MO, SC, WV) plan to start using this authority in FY 2019. CA, MD, MS, NE and NH reported “no” and 3 MCO states – KS, NY, ND – did not provide a response.

    ← Return to text

  15. U.S. Congress, House, HR 6, 115th Congress (2017-2018)., September 28, 2018, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf

    ← Return to text

  16. In April 2016, CMS issued a final rule on managed care in Medicaid and CHIP that provided a framework of plan standards and requirements designed to improve the quality, performance, and accountability of these programs. The current administration, however, is expected to release revised Medicaid managed care regulations for public comment.

    ← Return to text

  17. 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.

    ← Return to text

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

    ← Return to text

  19. CMS, through the Health Care Payment Learning and Action Network, developed an APM Framework to create a common framework for measuring progress toward VBP. Category 1 includes fee-for-service strategies with no link to payment quality; Category 2 includes fee-for-service strategies with a link of payment to quality and value; Category 3 includes alternative payment models built on fee-for-service architecture; and Category 4 includes population-based payment. Information found at https://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network.

    ← Return to text

  20. Ibid.

    ← Return to text

  21. 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.

    ← Return to text

  22. Arkansas reported plans to implement an MCO program for the first time in FY 2019.

    ← Return to text

  23. CMCS Information Bulletin, Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates (Baltimore, MD: Centers for Medicare and Medicaid Services, June 30, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf.

    ← Return to text

  24. Six states reported that they had no MLR specified in MCO contracts as of July 1, 2018 (GA, HI, NH, TN, TX and WI) but are monitoring MLR reporting by plans. Tennessee and Texas both noted that they rely on a methodology that controls for excess MCO profits.

    ← Return to text

  25. One of the 28 states reporting a PHP arrangement that is not included in Exhibit 12 is Alabama, which reported having a PHP for maternity care.

    ← Return to text

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

    ← Return to text

  2. Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concepts (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/.

    ← Return to text

  3. 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/.

    ← Return to text

  4. 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/.

    ← Return to text

  5. 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/.

    ← Return to text

  6. MaryBeth Musumeci, Robin Rudowitz, Elizabeth Hinton, Larisa Antonisse, and Cornelia Hall, Section 1115 Medicaid Demonstration Waivers: A Look at the Current Landscape of Approved and Pending Waivers (Washington, DC: Kaiser Family Foundation, September 2018), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/

    ← Return to text

  7. 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.)

    ← Return to text

  8. Consumer Assessment of Healthcare Providers and Systems

    ← Return to text

  9. Jack Hoadley, Karina Wagnerman, Joan Alker, and Mark Holmes, Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities, Georgetown University Center for Children and Families and the University of North Carolina, NC Rural Health Research Program, (Washington D.C., June 2017), https://ccf.georgetown.edu/wp-content/uploads/2017/06/Rural-health-final.pdf.

    ← Return to text

  10. Project ECHO (Extension for Community Health Outcomes) increases access to specialty treatment in rural and underserved areas by using telehealth to link front-line clinicians with specialist mentors at an academic medical center or hub.

    ← Return to text

  11. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, expected to be signed into law as this report was being finalized, contains a number of provisions related to Medicaid’s role in helping states provide coverage and services to people who need substance use disorder (SUD) treatment, particularly those needing opioid use disorder (OUD) treatment. For example, the Act includes new authority to cover IMD services for up to 30 days in a year for persons with an SUD.

    ← Return to text

Long-Term Services and Supports Reforms
  1. Steve Eiken, Kate Sredl, Brian Burwell, and Angie Amos, Medicaid Expenditures for Long-Term Services and Supports in FY 2016 (IAP: Medicaid Innovation Accelerator Program: IBM Watson Health May 2018), https://www.medicaid.gov/medicaid/ltss/downloads/reports-and-evaluations/ltssexpenditures2016.pdf.

    ← Return to text

  2. 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), http://www.kff.org/medicaid/report/medicaid-section-1115-managed-long-term-services-and-supports-waivers-a-survey-of-enrollment-spending-and-program-policies/.

    ← Return to text

  3. 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.

    ← Return to text

  4. US Department of Health and Human Services, Long-Term Services and Supports: Direct Care Worker Demand Projections 2015-2030 (Health Resources and Services Administration Bureau of Health Workforce, US Department of Health and Human Services, March 2018), https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/hrsa-ltts-direct-care-worker-report.pdf

    ← Return to text

  5. In FY 2019, Montana is eliminating live-in caregiver services and children’s case management under the 1915(c) waiver for individuals with I/DD and eliminating occupational therapy, dietician/nutrition services, overnight support, and companion services from the Severe Disabling Mental Illness (SDMI) waiver.

    ← Return to text

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

    ← Return to text

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

    ← Return to text

  8. Rebecca Coughlin, Johanna Ward, Noelle Denny-Brown, et al. Final Report: Money Follows the Person Demonstration: Overview of State Grantee Progress, January to December 2016, (Centers for Medicare and Medicaid Services, September 2017), https://www.medicaid.gov/medicaid/ltss/downloads/money-follows-the-person/2016-cross-state-report.pdf.

    ← Return to text

  9. 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.

    ← Return to text

  10. In June 2015, CMS issued an Informational Bulletin to clarify when and how Medicaid reimburses for certain housing-related activities, including individual housing transition services, individual housing and tenancy sustaining services, and state-level housing-related collaborative activities. CMS’s intent was to assist states in designing on-going benefits that support community integration for seniors, individuals with disabilities, and individuals experiencing chronic homelessness. Many of the services outlined in CMS’s Informational Bulletin were initially developed under the auspices of MFP...

    ← Return to text

  11. This count does not include states that have/had 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.

    ← Return to text

  12. 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..

    ← Return to text

  13. 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/.

    ← Return to text

  14. Arizona, Idaho, Minnesota, New Mexico, Pennsylvania, Tennessee, Texas, Virginia and Wisconsin.

    ← Return to text

  15. 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.

    ← Return to text

  16. 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.

    ← Return to text

  17. Delaware, Florida, Iowa, Massachusetts, and New Jersey.

    ← Return to text

  18. Rhode Island did not provide response to enrollment policy for dual eligible persons with I/DD.

    ← Return to text

Provider Rates and Taxes
  1. 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.

    ← Return to text

  2. Maryland was not able to report MCO rate changes for FY 2019 because rate development was not complete.

    ← Return to text

  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.

    ← Return to text

  4. The Deficit Reduction Act of 2005 modified section 1903(w)(7)(A) of the Social Security Act. This statute and the implementing regulations eliminated states’ ability to tax only Medicaid MCOs.

    ← Return to text

Benefits and Copayments
  1. 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.

    ← Return to text

  2. Centers for Medicare and Medicaid Services, Strategies to Address the Opioid Epidemic (Baltimore, MD: CMS, November 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.

    ← Return to text

  3. U.S. Congress, House, HR 6, 115th Congress (2017-2018)., September 28, 2018, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf

    ← Return to text

  4. Centers for Medicare and Medicaid Services, Neonatal Abstinence Syndrome: A Critical Role for Medicaid in the Care of Infants (Baltimore, MD: CMS, June 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818.pdf.

    ← Return to text

  5. Centers for Medicare and Medicaid Services, Neonatal Abstinence Syndrome: A Critical Role for Medicaid in the Care of Infants (Baltimore, MD: CMS, June 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818.pdf.

    ← Return to text

  6. U.S. Congress, House, HR 6, 115th Congress (2017-2018), September 28, 2018, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf

    ← Return to text

  7. Indiana Health Coverage Programs, IHCP bulletin, IHCP adds coverage of community health worker services (Indiana Health Coverage Programs, May 2018), http://provider.indianamedicaid.com/ihcp/Bulletins/BT201826.pdf.

    ← Return to text

  8. 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/.

    ← Return to text

  9. 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/.

    ← Return to text

  10. MaryBeth Musumeci, Robin Rudowitz, and Elizabeth Hinton, Approved Changes in Indiana’s Section 1115 Medicaid Waiver Extension (Washington, DC: Kaiser Family Foundation, February 2018), https://www.kff.org/medicaid/issue-brief/approved-changes-in-indianas-section-1115-medicaid-waiver-extension/.

    ← Return to text

  11. Benefit changes are denoted with (+) if they have a positive impact from the beneficiary’s perspective, regardless of budget impact. 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 (such as state coverage of behavioral services for children with autism spectrum disorder) are also denoted with (nc).

    ← Return to text

Pharmacy and Opioid Strategies
  1. CMS Medicaid Drug Rebate Program website: https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html.

    ← Return to text

  2. 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/.

    ← Return to text

  3. Gene therapy is used to treat or prevent genetic diseases by seeking to augment, replace or suppress one or more mutated genes with functional copies. CAR T-cell therapy is a form of immunotherapy that uses specially altered T cells (part of the immune system) collected from the patient to fight cancer.

    ← Return to text

  4. Richard Mark Kirkner, Gene Therapy: Must Sky-High Prices ‘Come on Down’ Before the Price Is Right?, (Managed Care Magazine, July 2, 2018; https://www.managedcaremag.com/archives/2018/7/gene-therapy-must-sky-high-prices-come-down-price-right.

    ← Return to text

  5. New York State Medicaid Drug Utilization Review (DUR) Board Meeting Summary for April 26, 2018; https://www.health.ny.gov/health_care/medicaid/program/dur/meetings/2018/04/summary_durb.pdf.

    ← Return to text

  6. Wisconsin Department of Health Services, Family Care, Family Care Partnership, and PACE Enrollment Data, (Wisconsin Department of Health Services, July 2018), https://www.dhs.wisconsin.gov/familycare/reports/enrollmentdata.pdf.

    ← Return to text

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

    ← Return to text

  8. Substance Abuse and Mental Health Services Administration (SAMHSA), 2016 National Survey on Drug Use and Health: Detailed Tables (Rockville, MD: SAMHSA, September 2017), https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf

    ← Return to text

  9. “Understanding the Epidemic,” Centers for Disease Control and Prevention, accessed on September 2, 2018, https://www.cdc.gov/drugoverdose/epidemic/index.html.

    ← Return to text

  10. “Understanding the Epidemic,” Centers for Disease Control and Prevention, accessed on September 2, 2018, https://www.cdc.gov/drugoverdose/epidemic/index.html.

    ← Return to text

  11. U.S. Department of Health and Human Services, Determination That a Public Health Emergency Exists (HHS, October 26, 2017), https://www.hhs.gov/sites/default/files/opioid%20PHE%20Declaration-no-sig.pdf.

    ← Return to text

  12. Kaiser Family Foundation, Medicaid’s Role in Addressing the Opioid Epidemic (Washington, DC: Kaiser Family Foundation, February 2018), https://www.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/.

    ← Return to text

  13. 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.

    ← Return to text

  14. Centers for Medicare and Medicaid Services, Strategies to Address the Opioid Epidemic (Baltimore, MD: CMS, November 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.

    ← Return to text

  15. Neither letter addresses the use of federal Medicaid funds for IMD mental health services.

    ← Return to text

  16. U.S. Congress, House, HR 6, 115th Congress (2017-2018)., September 28, 2018, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf

    ← Return to text

  17. MaryBeth Musumeci and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/.

    ← Return to text

  18. 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).

    ← Return to text

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

    ← Return to text

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

    ← Return to text

  21. 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.

    ← Return to text

  22. In this year’s survey, Illinois did not report whether MCOs are required to follow Medicaid fee-for-service policies related to opioids and pharmacy benefit management.

    ← Return to text

  23. U.S. Congress, House, HR 6, 115th Congress (2017-2018)., September 28, 2018, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf

    ← Return to text

  24. Substance Abuse and Mental Health Services Administration, “Medication-Assisted Treatment (MAT),” (Substance Abuse and Mental Health Services Administration, last updated 02/07/2018), https://www.samhsa.gov/medication-assisted-treatment.

    ← Return to text

  25. 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.

    ← Return to text

  26. Substance Abuse and Mental Health Services Administration, “Medication-Assisted Treatment (MAT),” Substance Abuse and Mental Health Services Administration, last updated 02/07/2018, https://www.samhsa.gov/medication-assisted-treatment.

    ← Return to text

  27. Kathleen Gifford et al., Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Washington, DC: Kaiser Family Foundation, October 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

    ← Return to text

  28. Naltrexone does not carry abuse or diversion potential, and any provider licensed to prescribe medications can prescribe naltrexone. However, to prescribe or dispense buprenorphine, physicians must obtain a “waiver”. This process involves 1) registering with the Drug Enforcement Administration (DEA) to dispense controlled substances; 2) certifying intent to treat no more than 30 patients at one time in the first year; and 3) receipt of required training or certification. Physicians may apply to increase the allowable patient caseload, and if approved may treat up to 100 patients in their first year and up to 275 patients in subsequent years. Methadone may only be dispensed by opioid treatment programs certified by the Substance Abuse and Mental Health Services Administration (SAMHSA). Opioid treatment programs may also dispense buprenorphine.

    ← Return to text

  29. Kathleen Gifford et al., Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Washington, DC: Kaiser Family Foundation, October 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

    ← Return to text

  30. On last year’s budget survey, all 49 states that responded to a question about coverage of each of the MAT drugs reported coverage of buprenorphine and both oral and injectable naltrexone, but fewer states reported coverage of methadone.

    ← Return to text

  31. In this year’s survey, Illinois and Arkansas did not report whether their state covers Methadone to treat opioid use disorders.

    ← Return to text

  32. U.S. Congress, House, HR 6, 115th Congress (2017-2018)., September 28, 2018, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf

    ← Return to text

Challenges and Priorities in FY 2019 and Beyond Reported by Medicaid Directors and Conclusion
  1. MaryBeth Musumeci and Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/.

    ← Return to text

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/.

    ← Return to text

  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.

    ← Return to text

  3. Responses for North Dakota reflect information gathered during a telephone interview in early September 2018 and related research.

    ← Return to text