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Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015

Eligibility and Enrollment

The ACA included a number of significant changes for Medicaid eligibility and enrollment. One of the most significant changes extends Medicaid coverage to nearly all non-elderly low-income adults with incomes up to 138 percent of the federal poverty level (FPL) ($16,104 per year for an individual in 2014), ending the Medicaid eligibility exclusion for adults without dependent children or childless adults regardless of their income. However, the June 2012 Supreme Court ruling on the ACA effectively made the decision to implement the Medicaid expansion optional for states. The ACA also required states to transition to the use of Modified Adjusted Gross Income (MAGI) to determine Medicaid financial eligibility for children, pregnant women, parents and low income adults; eliminate asset limits for these same groups; transition children with income between 100 and 133 percent FPL from the Children’s Health Insurance Program (CHIP) to Medicaid; and to use new streamlined application, enrollment, and renewal processes. In addition, Medicaid agencies were required to coordinate enrollment processes with the new Marketplaces. Altogether, the eligibility changes in 2014 represent historic program changes.

Eligibility Standards

A total of 31 states reported at least one eligibility expansion in FY 2014 and eight states reported planned eligibility expansions in FY 2015; the ACA Medicaid expansion was the most commonly reported change. In contrast, four states made eligibility restrictions in FY 2014; no states reported restrictions in FY 2015. However, many states (24 in FY 2014, 6 in FY 2015) made changes to existing Medicaid eligibility pathways due to the availability of new coverage through the Marketplace; these changes are not counted as restrictions or expansions in this report.

Adult Coverage Changes Under the ACA

In FY 2014, 26 states including the District of Columbia expanded Medicaid for low-income adults, either under the direct provisions of the ACA or through waivers (Arkansas, Iowa, and Michigan). For FY 2015, New Hampshire implemented the Medicaid expansion in July 2014, and Pennsylvania received CMS approval of the Healthy Pennsylvania waiver that will expand Medicaid eligibility for low-income adults as of January 1, 2015. As of September 2014, the total number of states implementing the Medicaid expansion is 28 (including DC.) (Figure 4) Two states (Indiana and Utah) continue discussions about implementing the Medicaid expansion. Indiana has submitted a formal waiver application that is under review at CMS; elements of this waiver proposal are discussed throughout the report in relevant sections. Utah’s Governor continues to negotiate with CMS but has not yet made a formal submission. Medicaid officials in several states noted that expanding Medicaid to more low-income adults would be discussed in the next legislative session.

Figure 4: Current Status of State Medicaid Expansion Decisions

Figure 4: Current Status of State Medicaid Expansion Decisions

With more coverage options available across the income spectrum, some states made changes to existing Medicaid eligibility pathways to better conform to those options. These changes are included in Tables 1 and 2, but are not regarded as restrictions unless individuals previously covered through these pathways would not be expected to have access to coverage through these new options. States making these changes largely fall into three groups: 1) Medicaid expansion states changing Medicaid waiver coverage over 138 percent FPL; 2) States that have not adopted the expansion reducing Medicaid coverage over 100 percent FPL; and 3) States reducing or eliminating certain optional eligibility groups.

Medicaid expansion states changing Medicaid waiver coverage over 138 percent FPL

A few states had expanded eligibility to adults above 138 percent FPL prior to the ACA under waiver authority. With the availability of new coverage options in the Marketplace, seven states (California, Iowa, Massachusetts, New Mexico, New York, Rhode Island and Vermont) eliminated Medicaid coverage in their waivers for adults with incomes over 138 percent FPL. Three of these states (Massachusetts, New York and Vermont) have received or are seeking approval under a Medicaid waiver to use Medicaid funds to provide premium assistance that further subsidizes Marketplace coverage for individuals previously covered under their waiver.

In contrast, three states (Connecticut, DC and Minnesota) maintained coverage of adults with incomes over 138 percent FPL at the state’s regular match (FMAP.) Connecticut is maintaining its eligibility level for parents at 201 percent FPL.1 The District of Columbia is shifting its waiver for adults with income between 138 and 200 percent FPL to its state plan. Minnesota, which previously covered adults up to 275 percent FPL in MinnesotaCare, is maintaining waiver coverage for those up to 200 percent FPL and plans to shift this group to the new Basic Health Plan option in 2015.

Basic Health Plan
At least two states, New York and Minnesota, plan to implement a Basic Health Plan (BHP.) Under the BHP provisions of the ACA, a state receives 95 percent of what the federal government would have spent on premium and cost-sharing subsidies in the Marketplace for the eligible population. The state then provides coverage through a state-managed BHP. While the BHP is not part of Medicaid, it could affect Medicaid in these states. For example, Minnesota currently provides Medicaid to adults with incomes between 138 and 200 percent FPL who would likely be eligible for Marketplace subsidies; the state plans to move these adults to a BHP in 2015. New York plans to implement a BHP starting with immigrants under 200 percent FPL that currently receive coverage funded solely by the state; the BHP would then expand to another 200,000 adults between 138 and 200 percent FPL.
States that have not adopted the expansion reducing Medicaid coverage over 100 percent FPL

A few states that have not adopted the Medicaid expansion covered adults above 100 percent FPL before the ACA was enacted, largely through waivers. Some of these states made eligibility changes in response to the availability of new Marketplace coverage options in 2014. In states not adopting the Medicaid expansion in 2014, those with incomes above 100 percent FPL in most cases will be eligible for subsidies to purchase coverage in the Marketplace.

  • Indiana2 and Oklahoma reduced existing adult eligibility from 200 to 100 percent FPL in waiver renewals.
  • Wisconsin reduced eligibility levels for its existing waiver for adults from 200 to 100 percent FPL and expanded coverage to childless adults by eliminating the waiting list for coverage under its existing waiver.
  • Maine reduced state plan coverage for parents and caretakers from 133 to 105 percent FPL.
States reducing or eliminating certain optional eligibility groups

The availability of subsidized Marketplace coverage and expanded Medicaid coverage (in 28 states) provides new options for states to reconsider coverage policies for certain optional, limited benefit eligibility groups, such as the family planning group, some spend-down programs, and the Breast and Cervical Cancer Treatment (BCCT) program.3 While most states reported no current plans to change these eligibility pathways; a few states did report eliminations or reductions:

  • Nine states reported ending family-planning only coverage (Arizona, Arkansas, Delaware, Michigan, and Oklahoma in FY 2014; Illinois, Louisiana4, New Mexico and Pennsylvania in FY 2015.) Virginia also reduced eligibility for this group to 100 percent FPL in 2014 but plans to restore coverage to 200 percent FPL in 2015.
  • Five states (Hawaii, Illinois, and North Dakota in FY 2014 and Kentucky and Pennsylvania in FY 2015) reduced or eliminated eligibility for their medically needy programs for non-elderly non-disabled adults. In contrast, Minnesota increased the medically needy income limit for parents, children, and pregnant women.
  • Three states (Arkansas, Maryland in FY 2014; Kentucky in FY 2015) ended or plan to end the BCCT program.
Other Eligibility Changes for Adults

Two states made additional changes to Medicaid eligibility levels for adults aside from the changes made in response to the ACA. Montana increased the cap on enrollment in its Mental Health Services Plan (MHSP) waiver from 800 individuals to 2,000 individuals in FY 2014 and to 6,000 in FY 2015. Maine allowed its existing waiver that covered childless adults up to 100 percent FPL to expire, leaving most of the 9,000 individuals affected by this change without a coverage option, since eligibility for subsidies through the Marketplaces is limited to individuals with incomes above 100 percent FPL.

Eligibility Changes for Elderly Individuals and Those with Disabilities

Few states reported eligibility expansions or restrictions for this group. Two states (Florida in FY 2014 and New Jersey in FY 2015) reported expanding eligibility by increasing income and asset limits while two states (Arkansas and Louisiana) reported reducing or eliminating buy-in programs that allow working individuals with disabilities with higher amounts of income and assets than other elderly or disabled individuals to obtain Medicaid coverage. Two additional states reported more complex changes:

  • Indiana’s spend-down program was eliminated as a result of changing its methods for determining disability for Medicaid coverage.5 The spend-down program allowed those that otherwise qualified except for their income/assets to qualify after taking into account their medical expenses. Some of the 31,500 individuals affected by this decision obtained coverage in the Marketplace but some lost coverage. Some of the 31,500 that lost coverage also got assistance from the Medicare Savings Program (which provides Medicaid assistance with Medicare premiums and cost-sharing); the state increased the income limit for this program. Indiana also implemented a 1915(i) HCBS state plan amendment that will result in full Medicaid coverage for those with income up to 300 percent FPL and severe mental health conditions which will also cover some of those that lost spend-down coverage.
  • Louisiana eliminated optional coverage for aged and disabled individuals with incomes up to 100 percent FPL. Those that qualify for Supplemental Security Income (SSI, about 74 percent FPL) remain eligible for Medicaid, but approximately 8,000 Medicaid cases were closed as a result of the decision. The state also added an optional coverage group which will provide interim Medicaid-only benefits for those awaiting an SSI determination. Separately, the state implemented spend-down eligibility for four HCBS waivers.
Eligibility Changes for Pregnant Women and Children

Two states (Oklahoma and Louisiana) reduced eligibility for pregnant women to 138 percent FPL in FY 2014. Pregnant women losing eligibility in both states are likely eligible for coverage either through the Marketplace or CHIP in Louisiana. (As such, neither of these changes is counted here as a restriction.) Additionally, California and Rhode Island are working on initiatives to assist pregnant women with incomes above 138 percent FPL to purchase Marketplace coverage using Medicaid funding.

For children, the ACA implemented new policies across all states to help strengthen children’s coverage, such as providing Medicaid coverage to children aging out of foster care up to age 26 and requiring states to maintain eligibility thresholds for children that are at least equal to those in place at the time the ACA was enacted through September 30, 2019. In addition, the law established a minimum Medicaid eligibility level of 138 percent FPL for all children up to age 19. Prior to the ACA, the federal minimum eligibility levels for children varied by age, and the federal minimum for older children ages 6 to 18 was 100 percent FPL. As a result of the law, 21 states needed to transition children from CHIP to Medicaid in 2014; states still receive the enhanced CHIP federal matching rate for coverage of these children. (This change was not included in this report as an eligibility change since coverage for these children continues to be financed with Title XXI funds.)

See Tables 1 and 2 for more information on eligibility changes in FY 2014 and FY 2015.

Enrollment Procedures

In addition to changes in eligibility standards, some states were adopting options to further streamline application and renewal processes beyond those required by the ACA. States were also asked to report on implementation of hospital presumptive eligibility, efforts to coordinate with the Marketplaces, status of application backlogs, and plans for the next open enrollment period for Marketplace coverage.

Streamlining Options

Beyond changes required by the ACA, CMS offered states (in a letter dated May 17, 2013) the opportunity for expedited waivers for several new options that would further streamline application and renewal processes and facilitate enrollment. A majority of states implemented one of these options, namely to delay the annual Medicaid eligibility redeterminations that would normally have occurred during the first quarter of calendar 2014. For individuals scheduled for eligibility redetermination during this period, this waiver allowed Medicaid coverage to continue while staff were adjusting to the new MAGI income counting rules in all states and were focused on implementing the ACA Medicaid expansion in about half of states. Several states asked for and received extensions beyond March 31st that further delayed renewals for Medicaid enrollees. Also, as reported last year, about one third of states adopted an option to implement the MAGI rules before January 1, 2014. As of August 2014, CMS had approved the following states to use the remaining streamlining options:

  • Seven states (Arkansas, California, Illinois, Michigan, New Jersey, Oregon, and West Virginia) were approved to facilitate enrollment into Medicaid through administrative data transfer using Supplemental Nutrition Assistance Program (SNAP) data.
  • Four states (California, New Jersey, Oregon, and West Virginia) were approved to enroll parents based on income data available from their children’s eligibility application.
  • No state had an approved waiver to adopt 12 month continuous eligibility for adults under this option.

States were asked about their plans to adopt these options in FY 2015. Washington reported plans to adopt the administrative data transfer option, and Kansas planned to implement 12 month continuous eligibility for adults. Several states noted that they have adopted strategies (e.g. express lane eligibility) that use SNAP data to facilitate Medicaid enrollment or target outreach. New York also reported having adopted 12 month continuous eligibility for adults, but under their existing 1115 waiver.6

Hospital Presumptive Eligibility (HPE)

Starting in January 2014, the ACA allows qualified hospitals to make Medicaid presumptive eligibility determinations in accordance with an approved State Plan Amendment. CMS issued HPE rules governing the state implementation of HPE on January 24, 2014, which delayed adoption in many states.7 Only 11 states reported implementing HPE in January (with later CMS approval). At the time of the survey, an additional 18 states had implemented HPE and three other states with approved plans expected to implement in the fall. Another 17 states reported that they had submitted state plan amendments to CMS but had not yet received approval; these states were in various stages of discussions with CMS and were also developing training materials. Four states indicated that their HPE plans were still under development. States reported a great deal of variation in hospital participation levels and in the volume of applications received through HPE. Among states that implemented HPE early, hospital participation ranged from only a few in some states to the majority of Medicaid hospitals. Some states indicated that hospitals were not interested in participating because it was easy to enroll individuals in Medicaid using “real time” on-line eligibility systems.

Other Key Enrollment Issues Related to the Marketplace
Marketplace Interface. Almost all states experienced challenges in establishing a smooth interface between Medicaid and the Marketplace, whether the Marketplace was a Federally Facilitated Marketplace (FFM), State-Based Marketplace (SBM), or a Federal Partnership Marketplace (FPM). This interface required an unprecedented level of cooperation across agencies (within state government, and/or between states and federal agencies) and across IT systems. Medicaid programs with fully operational SBMs reported the fewest interface issues. In at least six states (Kentucky, Minnesota, New York, Rhode Island, Vermont, and Washington) the eligibility system is shared by Medicaid and the Marketplace, resulting in an absence of file transfer issues. Most states that relied on healthcare.gov for Marketplace enrollment (including all FFM and FPM states, as well as two Federally-supported SBM states) indicated that initial file transfers, which were “flat files”, were unusable. Most of these states report that they began receiving usable account transfers (rather than the flat files) sometime between March and June of 2014 and most states have adopted system modifications or other solutions to process applications. At the time of the survey, a limited number of states reported that they were still unable to interface with the FFM. All but one of the SBM states indicated that the Medicaid agency was able to transfer files to the SBM and most of the states relying on the Federal Marketplace website (30 of the 36) also indicated that they were able to send files to the Marketplace. Others indicated that this functionality was being developed.
Application Processing Backlogs. The majority of states (31) reported that as of June 1, 2014 they had a backlog of Medicaid applications; the relative size of the backlog, while not collected across all states, varied substantially. States reported a variety of reasons for the backlogs including the sheer volume of applications; limited administrative capacity; large influx of applications from the FFM between March and June; pending verifications for income, citizenship and identity; incompatible data transferred from the FFM; and duplicate applications. Some states indicated that as of the date of the survey the backlog had been eliminated. Most states were seeing significant reductions in the backlogs and hoped to eliminate them with the exception of unresolved system or data issues. Thirteen states were asked by CMS to update their mitigation plans over the summer. As states worked through these backlogs, a number of them noted that a sizeable share of the applications yet to be processed were due to duplicate applications or applications from individuals who had started an application in one place but had completed a separate application in another way (e.g. started with an application at healthcare.gov but then applied again through the state Medicaid office.)
Preparation for Next Open Enrollment Period. States were asked to describe any issues on which they were focusing in preparation for the next Marketplace open enrollment period (beginning November 15, 2014, for coverage in January 2015). Many states have made or are making systems modifications to create a more seamless transition of applications from the Marketplace to the Medicaid agency. At least one state (North Dakota) changed from an assessment state to a “determination state” in which the Marketplace will make Medicaid eligibility determinations. Some states will be increasing staff resources and adding training for eligibility staff and for Marketplace navigators and other assisters. A few states are changing their Marketplace model: Nevada and Oregon are moving from SBMs to “Federally-supported SBMs” and will use healthcare.gov for Marketplace applications and enrollment; Idaho and New Mexico are working on efforts to move from Federally-supported SBMs to fully State-based Marketplaces; Idaho reported plans to make this transition for the next open enrollment period while New Mexico is planning to make this transition at a later date. A number of states mentioned developing policies and notices related to renewal (of Medicaid and Marketplace coverage) was also a focus; many states noted that this will be the first year handling both renewals and new enrollments since the ACA was implemented (as noted earlier, a number of states obtained waivers from CMS last year to delay renewals that would have otherwise occurred during the open enrollment period last year.) Several states were concerned about having adequate time to make the necessary adjustments to their systems, procedures or policies if the federal government makes changes.

TABLE 1: CHANGES TO ELIGIBILITY STANDARDS IN ALL 50 STATES AND DC, FY 2014 and 2015

Eligibility Standard Changes
STATES FY 2014 FY 2015
(+) (-) (#) (+) (-) (#)
Alabama
Alaska
Arizona X X
Arkansas X X X
California X X X
Colorado X X
Connecticut X
Delaware X X
DC X
Florida X
Georgia
Hawaii X X
Idaho
Illinois X X X
Indiana X X X
Iowa X X
Kansas
Kentucky X X
Louisiana X X X X
Maine X X
Maryland X X
Massachusetts X X
Michigan X X
Minnesota X X
Mississippi
Missouri
Montana X X
Nebraska
Nevada X
New Hampshire X
New Jersey X X
New Mexico X X
New York X X
North Carolina
North Dakota X X
Ohio X
Oklahoma X
Oregon X X
Pennsylvania X X
Rhode Island X X X
South Carolina
South Dakota
Tennessee
Texas
Utah X
Vermont X X
Virginia X X X
Washington X
West Virginia X
Wisconsin X X
Wyoming
Totals 31 4 24 8 0 6

NOTES: DC, HI, MA, and VT are counted as expanding coverage through the adoption of the ACA Medicaid expansion even though these states had expanded full coverage to both adults and parents previously.
(+) denotes positive changes from the beneficiary’s perspective that were counted.
(-) denotes negative changes from the beneficiary’s perspective that were counted.
(#) denotes changes to Medicaid eligibility pathways in response to the availability of other coverage options such as the Marketplace.
SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2014.

Table 2: Eligibility Changes in the 50 States and the District of Columbia, FY 2014 and FY 20158

State

Fiscal Year Eligibility Changes
Alabama 2014
2015
Alaska 2014
2015  
Arizona 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. As part of the expansion, the state lifted the enrollment cap for childless adults in its existing 1115 waiver program and transitioned this group to the new Medicaid expansion adult group. (affected 208,000 individuals)
Adults (#): Eliminated Family Planning–only group in FY 2014. (affected 5,105 individuals)
2015  
Arkansas 2014 Adults (+): Implemented Medicaid expansion through an 1115 waiver as of Jan. 2014, increasing eligibility for adults up to 138% FPL. (affected 250,000 individuals)
Elderly and Disabled Adults (-): Eliminated the Buy-in for Workers with Disabilities program December 31, 2013.
Adults (#): Eliminated the Breast and Cervical Cancer Treatment Program in FY 2014. (affected 855 individuals)
Adults (#): Eliminated Family Planning–only group in FY 2014. (affected 57,877 individuals)
2015  
California 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under its existing 1115 waiver program to the new Medicaid expansion adult group.
Adults (#): Coverage of adults under the Health Care Coverage Initiative, a program that used Medicaid funds to cover adults with incomes between 133% and 200% FPL on a county-by-county basis under the state’s 1115 Bridge to Reform waiver, ended December 31, 2013.
Children (+): Maintained eligibility for former foster care youth who age out of Medi-Cal at age 21 six months ahead of the ACA requirement. (affected approx. 166 individuals per month)
2015 Pregnant Women (+): Plan to implement a new affordability and benefit wrap program using Medicaid funding for pregnant women over 133% FPL.
Colorado 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes lifting the enrollment cap in their existing 1115 waiver and transitioning those covered under this program to the new Medicaid expansion adult group.
Children (+): Implemented continuous eligibility for children. (affected 4,286 individuals)
2015 Children (+): Implement the option to eliminate the 5-year bar on eligibility for legally-residing immigrant children. (estimated to affect 1,699 individuals)
Connecticut 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their Low-Income Adult waiver program to the new Medicaid expansion adult group.
Adults (nc): Coverage for parents up to 201% FPL was maintained.
2015  
Delaware 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing 1115 waiver to the new Medicaid expansion adult group. (affected 6,500 individuals)
Adults (#): Eliminated Family Planning–only group. (affected 2,072 individuals)
2015  
District of Columbia 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing early expansion state plan group to the new Medicaid expansion adult group.
Adults (nc): Coverage for its existing 1115 waiver for adults above 138% FPL was maintained.
Adults (nc): Implemented Medicaid enrollment suspension for incarcerated adults.
2015 Adults (nc): Plan to transition adults with incomes above 138% FPL from a Medicaid waiver to Medicaid state plan. (estimated to affect 6,258 individuals)
Florida 2014 Elderly and Disabled (+): Increased the minimum monthly maintenance income allowance and excess standard for community spouses of institutionalized people. (The number of nursing home residents eligible for Medicaid is also affected by 2014 cost of living adjustments and increases in the average private pay nursing home rate.)
2015  
Georgia 2014
2015
Hawaii 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, for adults up to 138% FPL and transferred some existing waiver populations to Medicaid expansion.
Adults (#): Eliminated Medically Needy Spend-down coverage for non-elderly non-disabled adults in FY 2014.
2015  
Idaho 2014  
2015  
Illinois 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. (affected 385,000 individuals)
Adults (#): Medically Needy Spend-down coverage for parents was eliminated. (affected10,800 individuals)
2015 Adults (nc): Plan to transition The state’s existing 1115 waiver (Cook County Care) was extended through June 2014; adults will be transitioned to the new Medicaid expansion adult group July 2014.
Adults (#): Illinois is in the final year of operating its Family Planning waiver, which is being phased out. (estimated to affect 65,000 individuals)
Indiana 2014 Adults (#): Reduced income levels for the state’s existing 1115 waiver (HIP), for adults from 200% to 100% FPL per waiver renewal. (affected 11,900 individuals)
Adults (+): HIP enrollment cap for childless adults under the Healthy Indiana Plan was increased per waiver renewal.
Elderly and Disabled (-): Converted from 209(b) to 1634 for aged, blind and disabled. As a result 209(b) related spend-down is no longer available. Some of these individuals with income above 100% FPL are expected to have other coverage options in the Marketplace, under Medicaid through the Medicare Savings Program, or under the new BPHC Medicaid program (described below), but some are expected to lose coverage. (affected 31,500 individuals)
Elderly and Disabled (+): Increased the income eligibility level for the Medicare Savings Program. (affected 47,000 individuals)
Elderly and Disabled (+): Implemented a new program, Behavioral and Primary Healthcare Coordination (BPHC) under a 1915i state plan option. Adults with serious mental illness with income up to 300% FPL that do not otherwise qualify for Medicaid coverage or other third party coverage will qualify for full Medicaid benefits.
2015 Adults (Proposed): The state has submitted a waiver proposal, HIP 2.0, which would use the state’s existing HIP program as a platform for an alternative Medicaid expansion, increasing eligibility for adults up to 138% FPL. The waiver has not been approved by CMS at the time of this report.
Iowa 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, through an 1115 waiver (Iowa Health and Wellness Plan), increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing 1115 waiver (IowaCare) to the new Medicaid expansion adult group.
Adults (#): The state’s existing 1115 waiver (IowaCare) which covered adults up to 200% FPL expired December 31, 2013.
2015
Kansas 2014
2015
Kentucky 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL.
2015 Adults (#): Plan to eliminate Medically Needy Spend-down coverage for non-elderly non-disabled adults and optional Breast and Cervical Cancer Treatment Program in Jan. 2015. (estimated to affect 4,400 individuals and 480 individuals respectively)
Louisiana 2014 Elderly and Disabled (+): Implemented spend-down eligibility for four HCBS waivers (allows individuals to spend down to 300% federal SSI waiver eligibility level).
Elderly and Disabled (-): No longer determine eligibility for the optional coverage of aged and disabled individuals under 100% FPL. They are referred to SSA for determination under our 1634 agreement. (Closed 8,000 cases)
Elderly and Disabled (-): Reduced the income and resource standards for TWWIIA Basic coverage group (Medicaid Purchase Plan).
Elderly and Disabled (+): Added optional coverage group to implement the State Provisional Medicaid Program which will provide interim Medicaid-only benefits to eligible individuals until such time that a decision has been rendered on their SSI cash assistance application pending with the Social Security Administration.
Pregnant Women (#): Eliminated optional coverage of pregnant women with incomes between 133% and 200% FPL. Pregnant women over 133% moved to CHIP.
2015 Adults (#): Plan to eliminate Family Planning waiver for those over 138% FPL. Those with income below 133% FPL will move from waiver to state plan. (7,200 individuals)
Maine 2014 Adults (#): Reduced parent/caretaker income levels from 133% to 100% FPL. (affected 14,000 individuals)
Adults (-): Maine’s 1115 waiver that covered adults without dependent children up to 100% FPL expired. (affected 9,000 individuals)
2015  
Maryland 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing 1115 waiver to the new Medicaid expansion coverage group.
Adults (#): Eliminated Breast and Cervical Cancer Treatment Program in FY 2014.
2015  
Massachusetts 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, which covers adults up to 138% FPL. This includes transitioning approximately 256,207 adults covered under their existing 1115 waiver program to the new adult expansion group.
Adults (#): The state eliminated Medicaid waiver coverage for some adults with income over 138% FPL.
Adults (+): The state is using Medicaid funds to provide premium assistance to those previously covered under the state’s Medicaid waiver with incomes between 138% FPL and 300% FPL using Medicaid dollars.
Other (+): Cover adults 19 and 20 up to 150% FPL in MassHealth Standard. (27,300)
2015  
Michigan 2014 Adults (+): Implemented the Medicaid expansion as of April 1, 2014, through an 1115 waiver, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under an existing 1115 waiver program to the new adult expansion group. (350,000; 50,000 of whom were eligible for the state’s existing 1115 waiver)
Adults (#): Eliminated Family Planning –only group in FY 2014. (30,000)
2015  
Minnesota 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, which covers individuals up to 138% FPL. This includes transitioning some individuals from their existing MinnesotaCare 1115 waiver program to the new adult expansion group as well as those covered by their early expansion Medicaid state plan option.
Other (+): Medically needy income level for parents/caretakers, children and pregnant women increased to 133% FPL.
Adults (nc): Waiver renewal maintains MinnesotaCare coverage for 138 to 200% FPL group.
Adults (#): Reduced income level for MinnesotaCare adults from 275% to 200% FPL.
2015 Other (not Medicaid): Minnesota expects to transition to a Basic Health Plan for 2015.
Mississippi 2014
2015
Missouri 2014
2015
Montana 2014 Other (+): Raised cap on 1115 MHSP waiver from 800 to 2000 adults with SMI.
2015 Other (+): Raised cap on 1115 MHSP waiver from 2000 to 6000 adults with SMI.
Nebraska 2014
2015
Nevada 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. (88,407 childless adults and 36,202 parents/caretakers)
2015  
New Hampshire 2014
2015 Adults (+): Implemented the Medicaid expansion as of July 1, 2014, through an 1115 waiver (New Hampshire Health Protection Program), increasing eligibility for adults up to 138% FPL. (estimated to affect 50,000 individuals)
New Jersey 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing 1115 waiver to the new Medicaid expansion coverage group. (affected 100,000 individuals)
2015 Medically Needy (+): New Jersey will be implementing the “Miller Trust” option to enable additional individuals to qualify for community-based Long Term Supports and Services.9
New Mexico 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning some adults covered under their existing 1115 waiver (State Coverage Initiative) to the new Medicaid expansion coverage group. (affected 31,500 individuals)
Adults (#): Eliminated 1115 waiver coverage (State Coverage Initiative) between 138% FPL and 200% FPL.
2015 Adults (#): Plan to eliminate Family Planning–only group in FY 2015. (estimated to affect 37,400 individuals)
New York 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. As part of implementing the Medicaid expansion, the state transitioned some of adults covered under their existing 1115 waiver (Family Health Plus) to the new Medicaid expansion coverage group.
Adults (#): Eliminated 1115 waiver coverage (Family Health Plus) for adults with incomes above 138% FPL.
Adults (+): The state is pursuing waiver authority to establish the Qualified Health Plans Premium Assistance Program, which would provide premium assistance to those previously covered under the state’s Medicaid waiver with income between 138% FPL and 150% FPL using Medicaid dollars. (affected approx. 35,000 individuals)
2015 Other (Not Medicaid): Plans to start the Basic Health Plan with certain immigrants, who are currently paid for with state-only funds, with income up to 200% FPL. New York will then expand to an estimated 200,000 more people with incomes between 138% – 200% FPL.
North Carolina 2014
2015
North Dakota 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. (affected 10,000 individuals)
Adults (#): Eliminated Medically Needy Spend-down coverage for non-elderly non-disabled adults in FY 2014.
2015  
Ohio 2014 Adults (+): Implemented Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning some adults covered under their existing 1115 waiver (Cuyahoga County MetroHealth) to the new Medicaid expansion coverage group.
2015  
Oklahoma 2014 Adults (#): As part of a one-year extension, eligibility for individuals under the Individual Plan will be reduced from 200% FPL to 100% FPL. (affected 8,000 individuals)
Pregnant Women (#): Reduced eligibility level for pregnant women down to 138% FPL. (affected 4,731 individuals)
Adults (#): Reduced family planning waiver from 185% to 138% FPL. (affected 8,762 individuals)
2015  
Oregon 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. As part of implementing the Medicaid expansion, the state transitioned adults covered under their existing 1115 waiver to the new Medicaid expansion coverage group. (affected 60,000 individuals)
Adults & Children (#): Eliminated Medicaid Premium Assistance programs for adults and children with incomes below 200% FPL. (affected 5000 adults and 12,400 children)
2015  
Pennsylvania 2014
2015 Adults (+): Implementing the Healthy PA Section 1115 waiver January 1, 2015,which increases Medicaid eligibility for adults up to 138% FPL. (estimated to affect 600,000 individuals)
Adults (#): Plan to eliminate Medically Needy Spend-down coverage for non-elderly non-disabled adults. (estimated to affect 3,119 individuals)
Adults (#): Plan to eliminate Family Planning–only group. (estimated to affect 90,000 individuals)
Rhode Island 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing 1115 waiver to the new Medicaid expansion coverage group. (affected 50,000 individuals)
Parents (#): Eliminated Medicaid coverage for parents from 138% to 175% FPL. (affected 4,000 individuals)
2015 Pregnant Women (+): State will be exploring a Premium Assistance Program for Pregnant women over 133% FPL who wish to enroll in a qualified health plan.
South Carolina 2014
2015  
South Dakota 2014
2015
Tennessee 2014
2015
Texas 2014
2015
Utah 2014 Adults (#): Reduced eligibility for the state’s existing 1115 waiver (PCN) from 150% to 100% FPL. Enrollment cap remains in place.
2015
Vermont 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, covering adults up to 138% FPL. This includes transitioning some of the adults covered under their existing 1115 waiver to the new Medicaid expansion coverage group.
Adults (#): Reduced Medicaid eligibility levels to 138% FPL.
Adults (+): Implementing Vermont Premium Assistance which uses Medicaid funds to provide subsidies for Marketplace coverage in addition to marketplace subsidies. Also implementing the Vermont cost sharing reduction subsidies that reduce copays and deductibles for Marketplace products for individuals and families with incomes below 300% FPL.Children (nc); Increased income standard for children in Medicaid state plan to incorporate waiver expansion group.
2015 Other (nc): Submitted SPA to disregard asset tests for non-ABD medically needy.
Virginia 2014 Adults (#): Reduced income eligibility for Family Planning waiver to 100% FPL.
2015 Adults (#): Plan to restore income eligibility for Family Planning waiver to 200% FPL.Adults (+): Plan to implement 1115 waiver with limited benefits to extend coverage to adults with incomes below 100% FPL with severe mental illness.
Washington 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL. This includes transitioning adults covered under their existing 1115 waiver to the new Medicaid expansion coverage group.(affected 390,000 individuals)
2015  
West Virginia 2014 Adults (+): Implemented the Medicaid expansion as of Jan. 2014, increasing eligibility for adults up to 138% FPL.
2015  
Wisconsin 2014 Adults (+): Eliminated the enrollment cap that was part of the previous waiver for Childless Adults up to 100% FPL. (affecting 93,000 individuals)
Adults (#): Reduced the income limit for parents/caretakers and childless adults from 200% FPL to 100% FPL. (affecting 55,000 individuals)
2015  
Wyoming 2014
2015
Introduction Delivery System Reforms

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