Section 1115 Medicaid Expansion Waivers: A Look at Key Themes and State Specific Waiver Provisions
Appendix Table 1: Provisions Affecting Medicaid Expansion Adults in Arizona’s Section 1115 Medicaid Expansion Demonstration Waiver
Appendix Table 2: Arkansas’ Section 1115 Medicaid Expansion Demonstration Waiver Provisions
Appendix Table 3: Indiana’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions
Appendix Table 4: Iowa’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions
Appendix Table 5: Kentucky’s Proposed Section 1115 Medicaid Expansion Demonstration Waiver
Appendix Table 6: Michigan’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions
Appendix Table 7: Montana’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions
Appendix Table 8: New Hampshire’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions
|Appendix Table 1: Provisions Affecting Medicaid Expansion Adults in
Arizona’s Section 1115 Medicaid Expansion Demonstration Waiver[i]
|Element||Arizona Waiver Provision (with new amendment to be submitted)|
|Overviewii:||Changes Medicaid coverage for the ACA expansion population from 100-138% FPL from the traditional ACA expansion to the CARE Program, which imposes premiums of 2% of income; imposes co-payments up to 3% of income paid monthly into health savings accounts; and creates a healthy behavior incentive program.
State seeks waiver amendment that proposes changes to coverage for all “able-bodied” Medicaid adults, not only those who newly gained coverage under the ACA’s expansion, including a work requirement as a condition of eligibility, a 5-year lifetime limit on benefits, monthly income and work verifications and eligibility renewals, and a one-year lock-out for those who knowingly fail to report a change in income or make a false statement about work compliance.
|Duration:||1/1/17 through 9/30/21|
|Coverage Groups:||Newly eligible parents and childless adults from 100-138% FPL.
States seeks amendment that changes coverage for all “able-bodied” Medicaid beneficiaries age 19 or older, including expansion and traditional adults.
|Exempt Populations:||American Indian/Alaska Natives, people with serious mental illness, and people who are medically frail are exempt from participation.
Participation is voluntary for exempt groups and newly eligible adults at or below 100% FPL. These beneficiaries may fund a health savings account (described below), with the amount and timing of contributions at their discretion. No other program requirements apply.
For mandatory participants, hardship exemptions are available for each month that beneficiaries meet one of the following criteria during the prior month: death in the household or household has a qualifying expense (health care expense, home repair, or transportation repair) that exceeds 10% of countable gross income.
|Monthly Income Verification and Lock-Out:||State seeks amendment to require all “able-bodied” adult beneficiaries to report any change in family income on a monthly basis. Beneficiaries who knowingly fail to report change in family income would be disenrolled and locked out of coverage for one year.|
|Renewal:||State seeks amendment to permit state to redetermine eligibility of all “able-bodied” adults on a monthly basis.|
|Premiums:||Requires premiums of 2% of income or $25/month, whichever is less, paid into health savings account (described below).|
|Co-Payments:||Requires co-payments for certain services up to 3% of monthly or quarterly household income. Co-payments are paid into health savings account (described below) monthly for services already used, based on prior 6 months of service use, instead of at point of service.
Co-payments are at state plan amounts for the following services:
Premiums and co-payments are limited to 5% of quarterly household income.
|Disenrollment for Non-Payment:||Beneficiaries above 100% FPL may be disenrolled for nonpayment of premiums (after two-month grace period) but there is no lock-out period. Beneficiaries disenrolled for nonpayment may re-enroll at any time without paying past-due amounts. Beneficiaries who re-enroll within 90 days do not need to re-apply.
State may attempt to collect unpaid premiums but cannot report debt to credit agencies, place lien on beneficiary’s home, refer to debt collectors, file a lawsuit or garnish wages.
|Health Savings Accounts:||Health savings account funds may be used for health care related items on a list approved by CMS (with protocols that must be approved by CMS) if beneficiary pays premiums and co-payments timely and meets one healthy behavior target (described below).
Third parties such as employers, providers, or charitable organizations may make health savings account contributions for beneficiaries.
Any remaining account balance will be returned to beneficiaries who are no longer eligible for the demonstration.
|Healthy Behavior Incentives:||If beneficiaries self-attest to meeting one healthy behavior target, they may use their health savings account funds to pay for approved health care related services as described above. They also have the option to reduce their health savings account payments (excusing them from premium and co-payment liabilities for six months) or to roll unused health savings account funds over into the next year.
Healthy behavior targets include preventive health targets (annual well exam, flu shot, mammogram, or glucose screening) and chronic disease management targets (tobacco cessation, diabetes management, asthma management, or substance use disorder management).
State will provide education about healthy behavior program to beneficiaries.
|Delivery System and Benefits:||Mandatory Medicaid MCO enrollment (no changes from AZ’s existing Section 1115 waiver).|
|Work Requirement and Lock-Out:||State seeks amendment that would require all “able-bodied” Medicaid beneficiaries age 19 or older to be employed, actively seek employment, or attend school and/or participate in a job training program at least 20 hours per week.
Those subject to the work requirement would need to verify compliance each month.
Beneficiaries would be exempt from the work requirement if they:
Beneficiaries who knowingly make false statements regarding work verification would be disenrolled and locked out of coverage for one year.
State would gather information about whether work requirement applies during application process.
|Time Limit on Eligibility:||State seeks amendment to place a lifetime coverage limit of 5 years on “able-bodied” adults. People who are exempt from the work requirement (described above) also are exempt from the time limit. The lifetime coverage limit “clock” would start on the effective date of the waiver amendment.
The lifetime limit would exclude any time during which beneficiaries are:
State would gather information about whether time limit applies during application process.
|Status:||State must submit draft operational protocol to CMS for review and approval at least 90 days before planned CARE implementation. Protocol must cover contributions, accounts, and payment infrastructure as well as Healthy Arizona targets.
The state-level public comment period closed on March 29, 2017.
|SOURCE: Ariz. Health Care Cost Containment System, Special Terms and Conditions, #11-W-00275/9, 21-W-00064/9, approved Oct. 1, 2016-Sept. 30, 2012, amended, Jan. 18, 2017; SB 1092 Waiver Request Draft
NOTES: i- Arizona’s Section 1115 waiver (Arizona Health Care Cost Containment System (AHCCCS)) is much broader than the implementation of alternative ACA expansion model. Other waiver initiatives include (but are not limited to): Targeted Investments Program, to support physical and behavioral health integration for beneficiaries with behavioral health care needs; medical homes serving American Indians; and a Safety Net Care Pool to help defray the cost of uncompensated hospital care.
ii- The Arizona state legislature passed legislation in 2015 that requires AHCCCS to request amendments to the current Section 1115 waiver annually to allow for the implementation of work requirements, additional verification requirements, and a time limit on coverage for AHCCCS beneficiaries.
|Appendix Table 2: Arkansas’ Section 1115 Medicaid Expansion Demonstration Waiver Provisions|
|Element||Arkansas Waiver Provision (approved, as amended, with pending amendment)|
|Overview:||Uses Medicaid funds to pay Marketplace QHP or employer sponsored health insurance (ESI) premiums for all newly eligible adults statewide (estimated 200,000) under the ACA’s Medicaid expansion.
Waiver extension terminated health savings account program; established monthly premiums of up to 2% of household income for newly eligible beneficiaries from 100-138% FPL and a mandatory small group ESI premium assistance program; and provided for waiver of retroactive coverage.
State seeks waiver amendment to limit expansion eligibility to 100% FPL while still receiving ACA enhanced FMAP as of Jan. 1, 2018; require work as a condition of eligibility for expansion adults ages 19-49 as of Jan. 1, 2018; discontinue ESI premium assistance program as of Dec. 31, 2017; and eliminate retroactive eligibility for all expansion adults, including medically frail, as of July 1, 2017.
|Duration:||9/27/13 to 12/31/21
Eligibility effective 1/1/14
|Coverage Groups:||Newly eligible parents ages 19-64 between 17-138% FPL, and newly eligible adults without dependent children ages 19-64 between 0-138% FPL.
State seeks amendment that would limit eligibility for all expansion adults, including those determined medically frail, to 100% FPL, including 5% income disregard. Those above 100% FPL would leave Medicaid and enroll in Marketplace coverage with federal premium tax credits and cost-sharing reductions. Expansion eligibility for new applicants from 100-138% FPL would end as of Jan. 1, 2018. For those from 100-138% FPL who are enrolled as of Jan. 1, 2018, coverage would end at the first eligibility renewal or change in circumstances reported after Jan. 1, 2018.
|Exempt Populations:||People who are medically frail are exempt from QHP premium assistance and have choice of FFS coverage of same benefit package offered to new adult group or a benefit package that includes Medicaid state plan benefits.
Medically frail individuals age 21 and over who have access to cost-effective ESI through a participating employer may choose to enroll in ESI with Medicaid premium assistance. ESI premium assistance enrollees may be disenrolled if they are determined medically frail after they are enrolled.
American Indian/Alaska Natives are exempt from QHP or ESI premium assistance enrollment.
State seeks amendment that would eliminate the ESI premium assistance program on December 31, 2017.
|Enrollment, QHP Choice and Auto-Assignment:||Extension requires beneficiaries age 21 and over with access to cost-effective ESI through participating small group employers (2-50 employees) to participate in ESI.i
All other beneficiaries must enroll in a Marketplace QHP with choice of at least 2 silver level plans covering only essential health benefits. If beneficiaries do not choose a plan, they will be automatically assigned to one based on target minimum market share of demonstration beneficiaries in each QHP in region. Beneficiaries have 30 days to change QHP after auto-assignment and receive FFS coverage prior to QHP or ESI enrollment.
State seeks amendment that would eliminate the ESI premium assistance program on December 31, 2017. As of January 1, 2018, beneficiaries at or below 100% FPL enrolled in ESI premium assistance program would be transitioned to Medicaid premium assistance for QHP coverage.
State also seeks to eliminate QHP auto-assignment procedure based on target minimum market share. Auto-assignments instead would be distributed among QHP issuers in good standing with the Arkansas Insurance Department on an unspecified basis.
|Retroactive Coverage:||Under extension, three-month retroactive coverage is conditionally waived, after state completes eligibility determination mitigation plan and contingent upon timely eligibility determinations, provision of benefits during reasonable opportunity period for otherwise eligible individuals who attest to immigration status, and April 1, 2017 implementation of hospital presumptive eligibility program.
State seeks amendment to eliminate retroactive eligibility for expansion adults, including medically frail, beginning on or after July 1, 2017. Coverage for expansion adults would be effective the first day of the month in which the individual applied for coverage. State seeks to eliminate the requirements to complete an eligibility determination mitigation plan, provide benefits during a reasonable opportunity period, and implement hospital presumptive eligibility.
|Premiums:||State pays monthly premiums directly to QHPs. For ESI, employer must pay 25% of overall cost of coverage, except that state pays employer share for 3 years for those who offer non-grandfathered coverage as of Jan. 2017, and had not offered any coverage in 2016 or previously offered only grandfathered coverage.*
Extension requires beneficiaries with income from 100-138% FPL to pay monthly premiums of up to 2% of household income, regardless of whether coverage is obtained through ESI or QHP.
Premium payments are not a condition of Medicaid eligibility. State may attempt to collect unpaid premiums if beneficiaries do not make payments within two-month grace period but may not report debt to credit reporting agencies, place a lien on beneficiary’s home, refer to debt collectors, file lawsuit, seek a court order to garnish earnings, or sell debt to a third party collection agency.
Monthly premium requirements for those from 100-138% FPL would continue to apply as long as they are enrolled.
|Cost-Sharing:||No cost-sharing for beneficiaries at or below 100% FPL.
Extension requires beneficiaries from 100-138% FPL are responsible for Medicaid state plan level co-payments and co-insurance at the point of service, regardless of whether coverage is obtained through ESI or QHP. Providers can deny services for failure to pay cost-sharing. Medically frail > 21 are only subject to cost-sharing if they are enrolled in an ABP or ESI.*
Premiums and cost-sharing limited to 5% of monthly or quarterly income for both QHP and ESI beneficiaries.*
Cost-sharing at state plan amounts for those from 100-138% FPL would continue to apply as long as they are enrolled.
|QHP and ESI benefit packages:||QHPs and ESI plans provide services in the state’s Medicaid Alternative Benefits Package (ABP) for newly eligible adults. ABP is the same as Medicaid state plan benefits package.*|
|Federally qualified and rural health centers (FQHC/RHC):||QHP beneficiaries will have access to at least 1 QHP that contracts with at least one FQHC/RHC. ESI beneficiaries will have access to at least one FQHC/RHC through their ESI. If their ESI does not contract with an FQHC and RHC, beneficiaries may access through FFS.*|
|Prescription drugs:||Limited to the QHP formulary. Prior authorization within 72 hours instead of 24 hours.|
|Family planning providers:||State covers QHP/ESI out-of-network family planning providers on FFS basis.*|
|Wrap-around benefits:||Non-emergency medical transportation (NEMT) and EPSDT for 19 and 20 year olds provided FFS, except that state will not offer NEMT to individuals covered through ESI who do not demonstrate a need for such services.*|
|Incentive benefit:||Subject to CMS approval of a waiver amendment, state will offer an unspecified additional benefit not otherwise provided in the ABP for all beneficiaries at or below 100% FPL and for those from 100-138% FPL who pay premiums timely and “engage with a primary care provider.”|
|Work Requirement:||State seeks amendment to require non-medically frail beneficiaries ages 19-49 to participate in an approved work activity for 80 hours per month as a condition of eligibility, unless exempt, as of January 1, 2018. Work requirement would be phased in by age group.
Work activities would include some combination of the following:
Those subject to the work requirement would need to verify compliance electronically each month.
Beneficiaries would be exempt from the work requirement if they:
Beneficiaries would be identified as exempt at initial application and renewal, when circumstances change, and when exemption verification is submitted electronically.
Non-exempt beneficiaries who fail to meet work requirements for any three months during a “plan year” would be disenrolled. Disenrolled beneficiaries would not be permitted to re-enroll for the remainder of the calendar year (i.e., remainder of the “plan year”).
|Appeals:||Demonstration enrollees use the state fair hearing process for all appeals. (AR has approved SPA delegating Medicaid fair hearings for medical necessity and coverage issues for the new adults in QHPs to state department of insurance.ii Similar process to be used for those in ESI.*)|
|Cost-Effectiveness:||May use state-developed tests of cost-effectiveness for premium assistance that differ from those otherwise permissible.|
|Oversight:||State Medicaid agency and state insurance department will enter into MOU or agreement with QHPs regarding enrollment, payment of premiums and cost-sharing reductions, reporting and data requirements, notices, and audits.
State will require its vendor to enter into MOU with employers participating in the ESI premium assistance program.*
|Status:||Demonstration approved 9/27/13, first amendment approved 12/31/14, extension/second amendment approved 12/7/16.
State to submit operational protocol for ESI premium assistance program by April 30, 2017.*
Amendment submitted to CMS on June 30, 2017. The federal-level public comment period is open from July 11, 2017 to August 10, 2017.
|NOTES: *State seeks amendment that would eliminate the ESI premium assistance program as of December 31, 2017. i- Additional protocols must be submitted by April 30, 2017 with details on how enrollment and disenrollment in Arkansas Works. ii- Ark. State Plan Amendment #13-0013 MM4 (July 15, 2014), available at http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/AR/AR-13-0013-MM4.pdf.
SOURCE: Ark. Works, Special Terms and Conditions, #11-W-00287/6, approved Jan. 1, 2017-Dec. 31, 2021; Amendment Request to Arkansas Works Section 1115 Medicaid demonstration, submitted June 30, 2017.
|Appendix Table 3: Indiana’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions|
|Element||Indiana Waiver Provision, as approved, with pending extension request and amendment|
|Overview:||Implements the ACA’s Medicaid expansion by requiring most newly eligible adults with incomes from 0-138% FPL to pay monthly premiums by contributing to a Personal Wellness and Responsibility (POWER) health account. Newly eligible adults who pay premiums are eligible for HIP Plus, an expanded benefit package with co-payments only for non-emergency use of the ER. Those with incomes from 101-138% FPL who fail to pay premiums after a 60-day grace period are disenrolled from coverage and barred from re-enrolling for 6 months. Beneficiaries with incomes at or below 100% FPL who fail to pay premiums after a 60-day period receive HIP Basic, a more limited benefit package with state plan level co-payments. Also allows non-expansion parent/caretakers to pay premiums in lieu of co-payments for state plan services and offers optional Medicaid premium assistance for employer-sponsored insurance (ESI) for newly eligible adults over age 21.
Pending extension seeks to impose a three-month coverage lock-out for beneficiaries who do not timely complete the eligibility renewal process, a 1% premium surcharge for tobacco users beginning in the second year of enrollment, and require MCOs to implement additional outcome-based healthy behavior incentives related to tobacco cessation, substance use disorder treatment, chronic disease management, and employment.
Amendment to extension would require work as a condition of eligibility, change premiums to tiers instead of flat 2% of income, eliminate ESI premium assistance program, and require Transitional Medical Assistance parents up to 138% FPL to pay premiums like expansion adults.
|Duration:||2/1/15 to 1/31/18; seeking extension through 1/31/21|
|Coverage Groups:||Covers adults ages 19-64 with incomes from 0-138% FPL, including non-expansion (§ 1931) parent/caretakers, those eligible for Transitional Medical Assistance (TMA, formerly eligible as § 1931parent/caretakers), and adults newly eligible through the ACA’s Medicaid expansion (approximately 350,000 beneficiaries statewide).
Pending extension request seeks to require HIP 2.0 enrollment for pregnant women up to 138% FPL (health plans, benefits, and cost-sharing for this population would be the same as in the state’s traditional Medicaid program).
Amendment to extension request would change treatment of TMA enrollees by requiring those up to 138% FPL to pay premiums to access the Plus benefit package (with vision and dental).
Excludes children, seniors, and dual eligible beneficiaries. American Indian/Alaska Natives may opt out of the demonstration 30 days after enrollment. Newly eligible AI/ANs who remain in the demonstration have the more generous (HIP Plus) benefit package, with coverage effective on the date of application, and no premiums or co-payments.
Amendment to waiver extension would exempt refugees from demonstration for first 8 months after arrival.
|Coverage Effective Date:||Waives reasonable promptness so that HIP Plus coverage begins on the first day of the month in which a beneficiary makes an initial premium payment instead of the date on which beneficiary is determined eligible for Medicaid (retroactive to the application date). Beneficiaries have 60 days from the date of their eligibility determination to make this payment. However, individuals determined presumptively eligible (described below) will maintain presumptive Medicaid coverage for at least 60 days, and those found presumptively eligible who are subsequently determined fully eligible will have no gap in coverage.
For those at or below 100% FPL, HIP Basic coverage begins on the first day of the month in which the 60-day premium payment period expires. Once in HIP Basic, beneficiary cannot move to HIP Plus until eligibility renewal, receipt of rollover funds (described below) or at other times designated by the state.
Pending extension request would enroll those at or below 100% FPL who move from another Medicaid coverage group into HIP Basic immediately, without waiting for expiration of 60-day payment period, although these beneficiaries would have 60 days after HIP Basic enrollment to choose to pay a premium and enroll in HIP Plus.
|Fast Track Payments:||Effective April 1, 2015, state allows for an optional $10.00 fast track initial POWER account pre-payment that makes enrollment effective the first day of the month in which payment is received, once a beneficiary is determined eligible. However, the beneficiary cannot change MCOs for a year after making a fast track payment. The fast track payment is refundable if the applicant is determined ineligible. If the beneficiary’s regular monthly premium is less than $10.00, the MCO shall credit the remaining portion of the fast track payment to subsequent premium payments. If the beneficiary’s regular monthly premium is more than $10.00, the beneficiary will be billed the difference on the next POWER account invoice.|
|Presumptive Eligibility:||State shall include FQHCs, RHCs, CMHCs, and health department sites in an expanded presumptive eligibility program. Presumptive eligibility enables applicants to receive Medicaid-covered services as of the date that a qualified provider entity preliminarily determines that the applicant is financially and categorically eligible for Medicaid, while the final eligibility determination is pending with the state Medicaid agency.
To maintain the reasonable promptness waiver, the state must make final eligibility determinations for a certain percentage of presumptively eligible applicants (out of eligibility determinations made on all types of applications), beginning January 2016. If the state fails to meet this standard, the reasonable promptness waiver will be suspended for the next 6 months. The state shall propose the standard based on the first 9 months of the demonstration.
|Retroactive Coverage Transition Program:||Waives retroactive coverage of services incurred during the 90 days prior to Medicaid eligibility. However, for one year, the state will reimburse providers for services received up to 90 days prior to the effective Medicaid coverage date for non-expansion parent/caretaker relatives who were not determined presumptively eligible. If CMS determines that these beneficiaries are incurring costs that would have been reimbursed by Medicaid without the retroactive eligibility waiver (based on data provided by the state by Nov. 1, 2015), this transition program shall continue for the remainder of the demonstration.
Pending extension request seeks to eliminate the transitional prior claims payment program (described above).
|Lock-Out for Noncompliance with Renewals:||Pending extension request seeks to prevent expansion beneficiaries who do not complete eligibility renewal process from re-enrolling in coverage. Those who are disenrolled for failing to verify eligibility at renewal can re-enroll without a new application if they provide verification within 90 days of disenrollment. After 90 days of disenrollment, they would have to wait another 3 months before re-enrolling. This policy would not apply to those who are medically frail, pregnant, non-expansion parents and 19 and 20 year olds, and those who experience a qualifying event that prevented completion of the renewal process (obtained and subsequently lost private coverage, lost income after disqualification due to increased income, moved to another state and then returned, domestic violence victim, residing in disaster area in 60 days prior to disenrollment).|
|Delivery System and Health Savings Accounts:||Services provided by MCOs. MCOs also must bill and collect premiums from beneficiaries.
POWER accounts are jointly funded by beneficiary premiums and the state. POWER account funds are used to fund the first $2,500 of covered claims, except for preventive services required by 42 USC § 300gg-13,i the cost of which are not charged against POWER account funds. Other preventive services are covered, subject to a $500 annual cap, and are charged against POWER account funds.
State pays capitated rate to MCOs for services after the $2,500 POWER account funds are exhausted.
Within 30 days after demonstration approval, the state must submit an operational protocol to describe the process for collecting POWER account contributions.
|Beneficiary Premiums:||Monthly premiums apply to all beneficiaries from 0-138% FPL and are the greater of 2% of income (up to $28 per month for an individual at 138% FPL in 2017) or $1.00. Premiums for those at or below 5% FPL ($50 per month for an individual in 2017) will be $1.00/month. Premiums are a condition of eligibility only for non-medically frail beneficiaries from 101-138% FPL.
Pending extension request proposes charging higher premiums, at 3% of income, for tobacco users beginning in the second year of enrollment.
Amendment to extension request would add tobacco use question to Medicaid application to determine enrollees subject to surcharge.
Amendment to extension request would change premiums to tiered structure instead of flat 2% of income:
Cost-sharing (both premiums and co-payments) limited to 5% of quarterly household income. POWER account contributions cannot exceed 2% of household income (although each beneficiary will have their own POWER account).
Beneficiary premium amounts are adjusted at annual renewal and anytime the state is made aware of an income change during the current coverage period.
Beneficiary premiums shall be reduced by any POWER account contributions made by third parties, such as employers or non-profit organizations.
|State Contributions:||The state funds the difference between the beneficiary’s monthly premiums and the full $2,500 POWER account value. The state will make an initial $1,300 account contribution upon the beneficiary’s MCO enrollment, and any additional amount owed by the state to the MCO for services provided to the beneficiary shall be reconciled after 12 months.|
Consequences of Premium Non-Payment:
|Newly eligible adults from 101-138% FPL who do not make a premium payment within a 60-day grace period are disenrolled from coverage and locked out for six months. Prior to disenrollment, the state shall review all other bases of Medicaid eligibility and notify the beneficiary about the option to request a medical frailty determination, and the MCO must provide 2 written notices about the delinquent payment. Beneficiaries who are disenrolled for non-payment of premiums are not subject to the lock-out if they re-apply with verification of non-payment due to a “qualifying event,” such as moving to another state and then returning, experiencing domestic violence, or medical frailty.ii Individuals who never make their initial premium payment are not subject to the 6 month lock-out.
Newly eligible adults from 101-138% FPL who are medically frail who do not pay premiums are not terminated from coverage. Instead, these beneficiaries must continue to have access to the state plan benefit package,iii are subject to state plan co-payments for services, and continue to be billed for premiums.
Newly eligible adults at or below 100% FPL who do not make an initial premium payment within 60 days of their eligibility determination or who do not make a subsequent premium payment within the 60-day grace period are automatically enrolled in the HIP Basic plan. These beneficiaries will be subject to state plan co-payments for services, which may exceed the cost of monthly premiums applicable under HIP Plus.
Non-expansion parent/caretakers and newly eligible adults at or below 100% FPL who are medically frail who do not pay premiums retain their existing benefit package (described below) and are subject to state plan co-payments.
|Debts/Refunds Upon Disenrollment:||Payment of unpaid premiums is not a condition of Medicaid re-enrollment but may be owed as a debt.iv MCOs may attempt to collect unpaid premiums from beneficiaries but may not report debt to collection agencies, place a lien on beneficiary’s home, refer cases to debt collectors, file a lawsuit, seek a court order to garnish wages, or sell the debt to a third party for collection.
If beneficiaries have paid excess premiums,v they are owed a refund, subject to a 25% penalty if the beneficiary is terminated for non-payment of premiums.
|Healthy Behavior Incentives:||HIP Plus beneficiaries who make timely premium payments will be eligible to rollover their share of the unused POWER account balance at the end of 12 months. If the beneficiary completes age and gender appropriate preventive services, the rollover balance for HIP Plus beneficiaries will be doubled by the state, not to exceed the beneficiary’s total premium payments for the year.
HIP Basic beneficiaries can rollover unused POWER account funds, up to 50% of the amount of premiums required for HIP Plus, if they obtained unspecified age and gender appropriate preventive services.
Rollover funds can be used to reduce the required beneficiary premiums in the subsequent year. Debts may be collected from rollover account balances.
Pending extension seeks to require MCOs to implement HIP healthy behavior incentive initiatives targeting the following areas: tobacco cessation, substance use disorder treatment, chronic disease management (diabetes, weight management, pharmacy compliance), and employment (including completion of job training, work search, or educational activities through Gateway to Work program). The initiatives would provide incentives not only for program enrollment but also for completion of specified outcome milestones and targets. State would like to increase MCO incentive limit currently in place to $200 per initiative and $300 per member per year. State also will increase beneficiary and provider education about coverage of tobacco cessation services.
|Co-Payments for Non-Emergency Use of the ER:||All demonstration beneficiaries must pay a co-payment for non-emergency use of the ER, which is waived if the beneficiary calls the MCO’s 24-hour nurse hotline prior to using the ER. These co-payments must be refunded if the beneficiary has an emergency condition or is admitted to the hospital on the same day.
Grants § 1916(f) waiver authority for two-year demonstration (until Jan. 31, 2018) to test whether graduated co-payments ($8 for first visit and $25 for subsequent visits in the same year) discourage non-emergency use of the ER. ($25 exceeds the $8 maximum amount authorized by federal law.) This authority applies to all demonstration populations (newly eligible adults and non-expansion parent/caretakers) and requires a control group of at least 5,000 beneficiaries who are not subject to the increased co-payments.
Pending extension request seeks authority to make the emergency department co-payment policy permanent.
|Work Requirement:||Amendment to extension request would condition Medicaid eligibility for non-disabled adults on work, beginning in February, 2018, based on their length of HIP enrollment as follows:
7-9 months – 5 hours/week
Work activities include:
Enrollees are exempt from participating in a work activity if they are:
Work requirement would be phased in during second year of waiver extension, based on enrollee’s renewal date, with 6 month grace period.
Also seeks expenditure authority to use federal Medicaid funds for costs of orientation, assessment, job skills training, job search assistance, and tracking enrollee progress (estimated at $90/member/month).
Medicaid coverage for non-exempt beneficiaries that do not comply with work requirements would be suspended until they comply for a full month, beginning in the third year of waiver renewal.
|Benefit Packages:||Newly eligible adults 0-138% FPL who pay premiums receive HIP Plus, an ABP that includes the ACA’s essential health benefits and covers more services (including vision and dental and more generous prescription drug coverage) than HIP Basic.
Pending extension proposes adding chiropractic benefits to HIP Plus limited to 6 visits per year).
Newly eligible adults at or below 100% FPL who do not pay premiums receive HIP Basic, an ABP that includes the ACA’s essential health benefits but with fewer covered services (no vision or dental and less generous prescription drug coverage) compared to HIP Plus. HIP Basic includes all EPSDT services for 19 and 20 year olds, consistent with federal law.
Newly eligible adults who are medically frail must have access to the state plan benefit package.vi
Non-expansion parent/caretaker relatives and those receiving Transitional Medical Assistance receive the Medicaid state plan benefit package.
(Benefit package contents are specified in state plan amendments, not the waiver terms and conditions.)
Pending extension requests waiver of IMD payment exclusion for all beneficiaries ages 21 to 64 to authorize Medicaid payments for short-term stays up to 30 days and would add new SUD treatment services, including expanded inpatient detoxification and peer recovery supports and relapse prevention outpatient services, to benefit packages for all enrollees (cost sharing consistent with eligibility categories)
Amendment to extension request seeks federal Medicaid funds for enhanced reimbursement rate (as required by state statute) for FFS behavioral health rehabilitative services.
|Non-Emergency Medical Transportation:||Waives non-emergency medical transportation (NEMT) for newly eligible adults, except pregnant women and those who are medically frail, initially for demonstration year 1 and subsequently extended through year 3.
Pending waiver seeks to extend the NEMT waiver for the duration of the waiver.
|Optional Premium Assistance for ESI:||Newly eligible adults age 21 or older with access to ESI may choose to receive premium assistance and assistance with cost-sharing through a POWER account. The state will fund the POWER account with $4,000 per year for an individual or $8,000 per year for 2 adults in the same household covered by ESI. POWER account funds will be used to pay the state’s portion of the ESI premium and contribute to the employee’s ESI cost-sharing (deductibles, co-payments, co-insurance). Beneficiaries must contribute to their ESI premium by a payroll deduction of at least $1.00 but not less than 2% of their monthly income. The employer must contribute at least half of the employee’s premium, and the ESI benefit package must comply with the requirements for an approved Medicaid ABP.
Extension request seeks to allow all Medicaid eligible family members (spouses and children of HIP 2.0 beneficiaries receiving ESI premium assistance) to receive ESI premium assistance with wrap-around benefits and cost-sharing at state plan amounts. Those who are not eligible for HIP 2.0 would not have POWER accounts.
Amendment to waiver extension would end ESI premium assistance program.
|Next Steps:||Extension request is pending with CMS. Amendment to extension request subject to state-level public comment May 24, 2017-June 23, 2017. Amendment to extension submitted to CMS on May 25, 2017. The federal-level public comment period was open from June 9, 2017-July 9, 2017.|
|SOURCE: Healthy Ind. Plan (HIP 2.0), Special Terms and Conditions, #11-W-00296/5, approved Feb. 1, 2015-Jan. 31, 2018; Ind. Family & Soc. Servs. Admin., Healthy Ind. Plan Section 1115 Waiver Extension Application, submitted Jan. 31, 2017; Amendment Request to Healthy Indiana Plan (HIP) Section 1115 Waiver Extension Application, submitted May 25, 2017.
NOTES: i- These include all services rated “A” or “B” by the U.S. Preventive Services Task Force, immunizations recommended by the CDC Advisory Committee on Immunization Practices, and services for infants, children, adolescents, and women supported by HRSA guidelines.
ii- Other qualifying events include obtaining and subsequently losing private coverage, losing income after being disqualified for increased income, residing in a county subject to a disaster declaration within 60 days prior to termination for non-payment, and other circumstances specified by the state.
iii- Technically, these beneficiaries receive an ABP that is equivalent to the state plan benefit package.
iv- The debt is limited to the amount of the beneficiary’s pro rata share of claims paid during the coverage period or amounts permissible under Medicaid cost-sharing rules for deductibles, whichever is less.
v- Refunds are based on premium payments in excess of the beneficiary’s pro rata share of claims at disenrollment.
vi- Technically, these beneficiaries receive an ABP that is equivalent to the state plan benefit package.
|Appendix Table 4: Iowa’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions|
|Element||Iowa Waiver Provision (approved, as amended, with pending amendment)|
|Overview:||Covers newly eligible adults with incomes up to 138% FPL through Medicaid managed care.
Previously used Medicaid funds to pay Marketplace QHP premiums for newly eligible adults from 101-138% FPL statewide under the ACA’s Medicaid expansion, but that program was discontinued.
Amendment pending with CMS would eliminate 3-month retroactive eligibility for all Medicaid enrollees as of October 1, 2017, pursuant to state law.
|Duration:||12/10/13 to 12/31/19
Eligibility effective 1/1/14
|Coverage Groups:||Adults ages 19-64 up to 138% FPL.
People who have access to cost-effective ESI are required to receive premium assistance for ESI.
|Exempt Populations:||American Indian/Alaska Natives can voluntarily opt into demonstration.|
|Retroactive Eligibility:||Amendment pending with CMS would eliminate 3-month retroactive eligibility for all Medicaid enrollees, as required by state law.|
|Premiums and Healthy Behavior Incentive Program:||After the first year of enrollment, beneficiaries from 50-100% FPL pay premiums of $5/month. Non-payment of premiums for this group cannot result in disenrollment.
Also after the first year of enrollment, beneficiaries from 101-138% FPL pay premiums of $10/month.
Beneficiaries have a 90-day grace period to pay past-due premiums in full, after which beneficiaries from 101-138% FPL will be disenrolled. These individuals can re-apply for coverage at any time.
Unpaid premiums are considered a collectable debt owed to the state except for those who do not renew coverage and have not received services after the month of the last premium payment.
State must waive premiums for beneficiaries who self-attest to financial hardship. Opportunity to self-attest shall be on each premium invoice.
Beneficiary premiums waived for the first year of enrollment. In subsequent years, premiums are waived if beneficiaries complete specified healthy behavior activities. In year 1, these include completing an online health risk assessment and obtaining a wellness examination.
Beneficiaries have a 30-day grace period in the year in which premiums are due to complete the prior year’s healthy behaviors and have premiums waived for the remainder of the year.
Beneficiaries who have completed the health risk assessment and wellness exam can then complete specified preventive health-related activities, such as dental exams, smoking cessation, or activities related to diabetes or obesity, to earn financial rewards.
Those with income below 50% FPL, those who are medically frail, and American Indians/Alaska Natives are exempt from premiums but still may participate in the healthy behaviors program to earn financial rewards.
State submitted for CMS approval a protocol and must document through data and on-going monitoring that enrollees have access to providers in order to apply healthy behavior provisions. Any changes to the healthy behaviors protocol must be approved by CMS.
|Co-payments:||Beneficiaries only have co-payments for non-emergency use of the emergency room at state plan amounts.
Premiums and co-payments are limited to 5% of quarterly income.
|Benefits:||MCOs provide services in the state’s Medicaid Alternative Benefits Package (ABP) for newly eligible adults, based on the state employee plan benefits package. Because the new adult ABP is not aligned with the state plan benefit package, medically frail adults must have access to an ABP that includes the full Medicaid state plan benefit package.
Non-emergency medical transportation: state’s obligation to provide non-emergency medical transportation for newly eligible beneficiaries (unless medically frail or under age 21) is waived.
Dental: state provides dental benefits through a capitated commercial dental plan carve-out (PAHP). As of July 2017 for expansion and traditional adults, the full dental benefit package is offered in the 1st year of enrollment. To maintain access to full dental benefits without monthly premiums (up to $3/month, subject to 5% quarterly income cost-sharing cap) beginning in the second year of enrollment, enrollees with incomes over 50% FPL must complete healthy behaviors including an oral health self-assessment and preventive dental exam. Those who do not complete the healthy behaviors and do not pay premiums will receive basic dental services only (including emergency services and those necessary to complete healthy behaviors for the next year) except that the following groups are exempt from premiums: pregnant women, those in institutions only receiving a personal needs allowance, HCBS waiver enrollees, those in hospice, those eligible for IHS services, breast and cervical cancer treatment program enrollees, those who are medically frail, children under 21, and those who self-attest to financial hardship. Enrollees have a 90-day grace period to pay premiums, after which past-due premiums become a collectible debt owed to the state.
|Status:||Demonstration approved 12/10/13, amended 12/30/13, 5/1/14, 12/30/14, 7/31/15, 1/1/16, 5/31/16, 11/23/16, and 7/31,17.
Within 6 months of implementation and annually thereafter, state must hold forum for public comment.
|SOURCE: Iowa Wellness Plan, Special Terms and Conditions, #11-W-00289/5, approved Jan. 1, 2017-Dec. 31, 2019, amended Nov. 23, 2016; Iowa Wellness Plan Section 1115 Demonstration Amendment, August 2, 2017.|
|Appendix Table 5: Kentucky’s Proposed Section 1115 Medicaid Expansion Demonstration Waiver|
|Element||Kentucky Waiver Proposal (with pending amendment)|
|Overview:||Modifies the state’s existing Medicaid expansion by:
|Duration:||Request to implement 6 months following CMS approval for 5 years (plan to implement in the spring of 2017, except that work requirement may be phased in by county or region).|
|Coverage Groups:||Would include the adult expansion group and all other non-disabled adult Medicaid beneficiaries in most waiver provisions. Would allow CHIP-eligible children to enroll in the same health plan for which their Medicaid-eligible parents are eligible under the waiver.
Groups exempt from the waiver include former foster care youth up to age 26; individuals eligible for § 1915 (c) home and community-based services waivers; individuals eligible for Medicaid due to a disability, including those with an SSI determination; individuals over age 65; and individuals residing in an institution, such as a nursing facility. Exemptions from specific policies are noted below.
|Medical Frailty Determination||Those in hospice, with HIV/AIDS, or receiving SSDI would be automatically considered medically frail. Other individuals could self-identify to their MCO, be identified to the MCO by a provider, or identified by the MCO based on a state-approved health risk assessment and claims data. In all of these cases, the MCO would review and approve the medical frailty designation based on objective criteria established by the state.|
|Coverage Renewals and Lock-Out:||Would implement an annual open enrollment period for most adults that would vary for each beneficiary depending on when they enrolled in the program (spanning three months prior to Medicaid eligibility expiration and three months following). If beneficiaries fail to renew coverage during this period, they would be required to wait six months before being permitted to re-enroll in coverage, unless the individual completes a financial or health literacy course. Would exempt pregnant women, children, and individuals determined medically frail from this provision.|
|Income and Employment Verification and Lock-out:||Beneficiaries who knowingly fail to report changes to income or employment within 10 days would be disenrolled and locked out of coverage for six months. Disenrolled individuals could re-enroll in coverage before the end of the six-month lock-out period if they complete a financial or health literacy course, recertify eligibility, and pay any premiums.
Beneficiaries who fail to report would not be disenrolled if they met one of the following “good cause” exception criteria:
Amendment to application added this provision.
|Premiums:||Would impose sliding scale flat rate monthly premiums for most adults based on family income ranging from $1 for those with incomes under 25% FPL and up to $15 for individuals with incomes from 101-138% FPL in the first two years of enrollment. Premiums would be assessed based on family income rather than per person. Third parties such as non-profit organizations and providers may pay premiums on a beneficiary’s behalf. Children and pregnant women would be exempt from premiums.
Seeks to impose increasing premiums for individuals with income greater than 100% FPL beginning with a beneficiary’s third year of enrollment, which would exceed the premiums that beneficiaries at this income level would face in the Marketplace (2% of income).
|Effective Coverage Date:||Seeks to waive retroactive coverage for most adults (except for pregnant women and children) and requires individuals to pay their first month’s premium prior to the start of coverage. Individuals below 100% FPL who do not make a premium payment would have coverage start 60 days after they are determined eligible for Medicaid. Those above 100% FPL could not access coverage without a premium payment.
The state would develop a process for individuals to make an initial pre-payment to expedite the start of coverage.
Amendment to application removed proposal to expand presumptive eligibility sites to include county health departments and certain safety net providers.
|Disenrollment and Lock-Out for Non-Payment of Premiums:||Premiums are a condition of eligibility for those from 101-138% FPL unless medically frail. This group would be disenrolled from coverage for non-payment after a 60-day grace period and not allowed to re-enroll for six months unless they pay their past debt (2 months of premiums incurred during 60-day grace period); pay the premium for the reinstatement month; and participate in a financial or health literacy course.
Individuals below 100% FPL and all those who are medically frail who do not pay premiums would be enrolled in coverage after the 60-day payment period expires and would lose $25 from their incentive account (described below), and the incentive account would be suspended. In addition, those below 100% FPL who are not medically frail must pay state plan copayments for services received during the first 6 months of coverage. They can avoid these penalties before the expiration of 6 months by paying past-due premiums and completing a health or financial literacy course.
|Co-Payments:||Beneficiaries who pay premiums would not have any co-payments.|
|Deductible Accounts:||Would establish an account to which the state would contribute a $1,000 annual deductible that covers non-preventive healthcare services. Once the deductible is exhausted, Medicaid MCOs would cover additional services.|
|Incentive Accounts:||All adults under the waiver (including pregnant women and those receiving ESI premium assistance) would have an incentive account, which may be used to access additional benefits not otherwise covered, such as dental, vision, over the counter medications, and limited reimbursement for the purchase of a gym membership. Moving vision and dental services from the standard benefit package to the incentive account would be delayed for 3 months after waiver implementation to allow beneficiaries to accrue funds in the incentive account.
Enrollees would accrue incentive account funds by transferring 50% of any remaining deductible account funds each year and/or completing specified health-related or community engagement activities, such as participating in community service or job training or a health risk-assessment or passing the GED exam. However, community service or job training activities only qualify for account incentive funds to the extent that those hours exceed the minimum work activity requirement hours (described below).
Incentive account funds would be deducted for non-emergency use of the emergency room ($20 for the first visit, $50 for the second visit, and $75 for the third and subsequent visits). Beneficiaries also will be eligible for a $20 incentive account contribution for each year in which they avoid unnecessary emergency room visits. The state may consider a similar program in which incentive account funds could be earned for keeping all appointments in a certain period and would be deducted for missed health care appointments.
Former beneficiaries who remain employed and privately insured for 18 months could apply to receive the balance of their incentive account funds in cash, up to $500.
|Work Requirement and Lock-Out:||Would require all “able-bodied” working age adults to participate in a work activity, such as volunteer work, employment, job search, job training, education, or caring for a non-dependent relative or person with a disabling chronic condition, after three months of program enrollment as a condition of eligibility. After the third month of enrollment, all non-exempt members would be required to participate in a work activity 20 hours per week. Failure to meet the required work hours would result in suspended benefits until the person complies for a full month. New members who were previously enrolled more than three months (with a 5 year look back period), will be subject to the work requirement the first day of the first full month of enrollment. Current members who transition to Kentucky HEALTH would be subject to the work requirement upon transition, without a three-month grace period.
Would exempt children, pregnant women, individuals determined medically frail, students, and individuals who are the primary caregiver of a dependent from this requirement.
Beneficiaries would self-attest to work hours, and those who knowingly make false statements regarding work verification would be disenrolled and locked out of coverage for six months. Disenrolled individuals could re-enroll in coverage before the end of the six-month lock-out period if they complete a financial or health literacy course.
Amendment to application removed original request for graduated work requirement, which would have started at five hours/week (after three months of enrollment) and increased each quarter thereafter (up to maximum 20 hours/week). Amendment also added disenrollment and lock-out period for individuals who make false statements regarding work verification.
|Benefits:||Seeks to waive non-emergency medical transportation for the adult expansion group.
Seeks use Medicaid funds to cover out of pocket expenses (test fees) for completion of the GED exam for adults (both expansion and traditional Medicaid populations) without a high school diploma.
Seeks to implement pilot program in 10 to 20 counties to obtain federal matching funds for behavioral health services provided in IMDs through a waiver of the federal payment exclusion for non-elderly adults with short-term residential stays up to 30 days.
Would use state plan authority to elect the state employee health plan as the benefit benchmark for expansion adults but maintain all current state plan behavioral health services.
Children, pregnant women, medically frail individuals, and non-expansion adults (Section 1931 parents) would continue to receive the Medicaid state plan benefit package. The waiver application is unclear about whether the state would continue to cover private duty nursing.i
|Delivery System:||Would continue to use existing capitated Medicaid managed care organizations for all populations statewide (except those in ESI premium assistance). Seeks waiver authority to eliminate 90-day health plan choice period upon initial MCO enrollment.|
|Employer-Sponsored Insurance Premium Assistance Program:||Would expand Medicaid premium assistance to include all adults who have access to cost-effective employer-sponsored insurance (ESI). Medicaid and CHIP-eligible children also would enroll in their parent’s ESI with premium assistance. Participation would be optional during the first year of Medicaid enrollment, and mandatory after the beneficiary’s second year of Medicaid enrollment and employment.
Enrollees would receive an advance payment to cover the employee’s share of the premium before it is deducted from their paycheck. Enrollees would be subject to the same Medicaid premiums as other adults under the waiver, and the ESI premium reimbursement payment would be reduced by the amount of the beneficiary’s Medicaid premium. Individuals would receive Medicaid fee-for-service wrap-around coverage for benefits not covered and all cost-sharing under the employer plan.
|Status:||Original waiver application is pending with CMS. Amendment to pending application submitted July 3, 2017. Federal public comment period for amendment will run concurrently with state public comment period from July 3, 2017 through August 2, 2017. Public hearings are being held July 14, 2017 (Somerset, KY) and July 17, 2017 (Frankfort, KY).|
SOURCE: Kentucky HEALTH, Pending Application, submitted Aug. 24, 2016. Amendment Request to Kentucky HEALTH, submitted July 3, 2017.
NOTES: The waiver application lists private duty nursing as not covered for expansion adults, although the state’s response to the public comments indicates that it will not remove private duty nursing from the benefit package, and the application indicates that the private duty nursing cut has been removed from the budget neutrality calculation. Compare page 24, Table 3.2.12(B) with pages 45 and 56 of the Kentucky waiver application submitted to CMS.
|Appendix Table 6: Michigan’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions|
|Element||Michigan Waiver Provision (approved, as amended on December 17, 2015)|
|Overview:||Covers childless adults ages 19 to 64 from 0 to 138% FPL statewide through Medicaid managed care. Requires copayments at state plan amounts for all beneficiaries, which may be reduced by participating in specified healthy behavior activities. Copayments are paid into health savings accounts monthly based on the average copayments for services used in the previous six months. Also requires beneficiaries 100-138% FPL to pay monthly premiums (2% of income) into health savings accounts. Beneficiaries cannot lose or be denied Medicaid eligibility, be denied health plan enrollment, or be denied access to services, and providers may not deny services, for failure to pay copays or premiums.
Beginning April 2018, beneficiaries with incomes above 100% FPL who are not medically frail will choose between 2 options: continued coverage through Medicaid managed care or Marketplace QHP coverage with Medicaid premium assistance and cost-sharing subsidies. Those choosing Medicaid managed care must meet a healthy behavior requirement after a one-year grace period.
|Duration:||12/30/13 to 12/31/18. Enrollment began 4/1/14.|
|Coverage Groups:||Adults ages 19-64 up to 138% FPL (childless adults 0-138% FPL, non-working parents from 37-138% FPL, and working parents from 64-138% FPL).i|
|Exempt Populations:||Noncitizens eligible only for emergency services, Program for All-Inclusive Care for the Elderly (PACE) participants, and individuals residing in intermediate care facilities for individuals with intellectual and developmental disabilities (ICFs/IDD).
As of April 2018, newly eligible adults above 100% FPL who are medically frail will remain in Medicaid managed care and are not subject to being transferred to a Marketplace QHP with Medicaid premium assistance if they do not complete a healthy behavior (described below).
|Premiums:||Beneficiaries above 100% FPL pay monthly premiums in the amount of 2% of income after six months of enrollment.
Beneficiaries cannot lose or be denied Medicaid eligibility, be denied health plan enrollment, or be denied access to services, and providers may not deny services for failure to pay premiums. This applies to both those in Medicaid managed care and in QHP coverage, when that option becomes available in April 2018.
Cost-sharing and premiums cannot exceed 5% of household income.
|Co-Payments:||All demonstration beneficiaries have cost-sharing obligations based on their average prior 6 months of copays, billed at the end of each quarter. Cost-sharing is paid into health savings accounts and can be reduced through compliance with healthy behaviors. Amount of cost-sharing is based on state plan amounts and not changed from what would have been collected without the waiver.ii Cost-sharing for beneficiaries receiving coverage through Marketplace QHPs, when that option becomes available in April 2018, also will be limited to Medicaid state plan amounts.
Beneficiaries cannot lose or be denied Medicaid eligibility, be denied health plan enrollment, or be denied access to services, and providers may not deny services for failure to pay copays. Copays in excess of 2% of income may be reduced through compliance with healthy behaviors. Cost-sharing and premiums cannot exceed 5% of household income. These provisions apply to beneficiaries in Medicaid managed care and those in QHP coverage.
|Health Savings Account and Healthy Behavior Protocols:||Health savings account and healthy behavior protocols were developed by the state and approved by CMS. The health savings account protocol describes the online accounts used by beneficiaries enrolled in MCOs and the healthy behavior protocol describes the services beneficiaries can engage in to decrease cost-sharing requirements and how engaging in these activities decreases their required cost-sharing. Changes to the protocols are also subject to CMS approval.iii
The state must submit a revised healthy behavior protocol to CMS by July 1, 2017 to implement the new healthy behavior requirements for non-medically frail beneficiaries with incomes above 100% FPL as of April 2018; these requirements cannot be more restrictive than those approved in August 2014. These beneficiaries will have a one-year grace period to complete a healthy behavior before they are subject to being moved from Medicaid managed care to Marketplace premium assistance. Enrollees who move from Medicaid managed care to Marketplace premium assistance (for failure to complete a healthy behavior) will be automatically transitioned without additional eligibility determinations. Those who are newly enrolled or whose income increases above 100% FPL in or after April 2018, will have one year of Medicaid managed care coverage to complete a healthy behavior before they are subject to QHP enrollment. By April 1, 2017, the state must submit a transition plan for how the new waiver provisions will be implemented for beneficiaries above 100% FPL in April 2018.
|Delivery Systems and Benefits:||No Medicaid benefits are waived.
Medicaid MCOs and PIHPs (for mental health and substance abuse services) are used to serve the newly eligible population. Beneficiaries in Medicaid managed care receive an Alternative Benefits Plan (ABP) that contains the same benefits as the state plan benefit package.
Beneficiaries receiving Medicaid premium assistance for Marketplace coverage (beginning in April 2018) will receive an ABP that may be specific to the QHP in which they are enrolled. Michigan will provide wrap-around coverage on a fee-for-service basis for non-emergency medical transportation, EPSDT and family planning services and supplies including access to out-of-network family planning providers for beneficiaries in QHPs. These beneficiaries will also have access to at least one QHP in each service area that contracts with an FQHC/RHC. QHP enrollees may have prescription drug prior authorization requests decided within 72 hours instead of 24 hours, with a 72-hour supply dispensed in an emergency.
Those newly determined eligible for waiver coverage will initially be placed in fee-for-service until an MCO is selected or auto-assignment occurs.
|Plan Choice and
|Enrollment broker assists beneficiaries with MCO selection before relying on auto-assignment.
According to the waiver, MCO auto-assignment first takes into account beneficiary’s prior or current MCO history and then MCO affiliation of beneficiary’s historic providers.
In rural counties,iv there will only be one MCO. In all other areas, beneficiaries will have a choice of MCOs. There will be one PIHP per region.
MCO lock-in for 12 months after initial 90 days to switch plans.
The state will develop an auto-assignment methodology for QHP enrollment when that option becomes available in April 2018.
|Cost-effectiveness:||Michigan may apply state-developed measures in evaluating the cost-effectiveness of Marketplace premium assistance.|
|Status:||Demonstration approval 12/30/13, amended 12/17/15, and 6/7/16.|
SOURCE: Healthy Michigan Demonstration, Special Terms and Conditions, # 11-W-00245/5, approved Dec. 30, 2013-Dec. 31, 2018, amended Dec. 17, 2015.
NOTES: i- Childless adults ages 19-64 from 0 to 35% FPL eligible for Michigan’s limited benefit package covered by the Adult Benefits Waiver that existed prior to initial implementation of the Healthy Michigan Plan transitioned to full Medicaid coverage as part of the new expansion group.
ii- Beneficiaries are subject to co-pays according to the current state plan (inpatient hospital admission (except emergent admission), $50; non-emergency use of the ER, brand-name drugs, dental visit, or hearing aid, $3; physician, podiatry, or vision office visits, $2; outpatient hospital or chiropractic visit or generic drugs, $1).
iii- Health savings account protocol is Attachment E, and the healthy behaviors protocol is Attachment F of the waiver’s Special Terms and Conditions.
|Appendix Table 7: Montana’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions|
|Element||Montana Waiver Provision|
|Overview:||Covers approximately 70,000 newly eligible adults through a managed fee-for-service (FFS) Third Party Administrator (TPA).
Requires premiums up to 2% of income for newly eligible beneficiaries from 51-138% FPL receiving services through the TPA. Individuals between 101-138% FPL who do not pay their premiums will be dis-enrolled from Medicaid after notice and a 90-day grace period and not allowed to re-enroll until past due premiums are paid or assessed against state income tax refunds by the end of the calendar quarter. Beneficiaries subject to premiums will receive a credit toward accrued co-payments up to 2% of income.
The state will implement twelve month continuous eligibility for all newly eligible adults.
|Duration:||1/1/16 to 12/31/20, pending state legislative reauthorization of the HELP Program beyond June 30, 2019. If HELP Program is not reauthorized, the state will terminate the waiver.|
|Coverage Groups:||Covers newly eligible adults ages 19-64 (parents with incomes 50-138% FPL and childless adults with incomes 0-138% FPL).|
|Exempt Populations:||People with incomes at or below 50% FPL; American Indians/Alaskan Natives; people who have exceptional health needs including but not limited to medical, mental health or developmental conditions (including people who are medically frail); people who live in regions where there are an insufficient number of providers contracted with the TPA; people who require continuity of coverage not available or effectively delivered through the TPA.
Individuals exempt from the TPA are also exempt from all demonstration provisions (including premiums) except 12-month continuous eligibility.
The waiver application indicated that medically frail beneficiaries will be identified through questions on the Medicaid application and can request an exemption from TPA enrollment at any point thereafter. The 1915(b) selective contracting waiver application also provided that the TPA will refer medically frail individuals that it identifies to the state.
|Renewal Simplification:||Twelve month continuous eligibility established for newly eligible adultsi regardless of the delivery system through which they receive benefits (i.e. even if they are exempt from the TPA).ii|
|Premiums:||Newly eligible adults from 51-138% FPL receiving services through the TPA will pay premiums equal to 2% of household income. Beneficiaries may report changes in income to have premiums re-calculated for the following quarter.
Beneficiaries from 101-138% FPL can be dis-enrolled for failure to pay premiums after notice and a 90-day grace period. Re-enrollment when overdue premiums are paid or the state Department of Revenue assesses the premium debt against income tax refunds, no later than the end of the calendar quarter. Re-enrollment shall not require a new application. The state shall establish a process to exempt beneficiaries from dis-enrollment for good cause.
Authority to charge premiums is contingent upon the state demonstrating the ability to electronically track out-of-pocket costs quarterly and CMS’s approval of the state’s preventive services protocol (describing services exempt from co-payments).
Third parties are permitted to contribute toward beneficiaries’ premium and co-payment obligations.
|Co-Payments:||Beneficiaries subject to premiums will receive a credit toward accrued co-payments up to 2% of income.
Co-payments will be at state plan amounts with certain services exempt including preventive health care services, immunizations and medically necessary health screenings.iii
Providers may not deny services for failure to pay copayments for individuals below poverty.
All cost-sharing (including premiums and co-payments) is limited to 5% of quarterly household income.
|Delivery System and Benefits:||Most newly eligible Medicaid beneficiaries will be enrolled in the TPA. The TPA will be a commercial insurer that already has an established provider network in the state. The state will contract with the TPA to administer the delivery of and payment for services, establish a provider network, reimburse providers on behalf of the state, collect beneficiary premiums, and assume other administrative functions. The TPA is part of the § 1915(b) selective contracting waiver, not the § 1115 waiver.
Beneficiaries will receive an ABP benefit package according to a SPA. The ABP for newly eligible individuals enrolled in the TPA will include all services in the Medicaid state plan benefit package except long term care services. Newly eligible adults who are exempt from TPA enrollment will receive an ABP that includes long-term care services through the state’s existing fee-for-service system.
The Section 1915(b) waiver application provides that certain benefits, such as non-emergency medical transportation and dental services, will be provided outside TPA.
|Status:||Demonstration approval 11/2/15 (effective 1/1/16).|
SOURCE: Montana Health and Economic Livelihood Partnership (HELP) Program, Special Terms and Conditions, # 11-W-00300/8, approved Jan. 1, 2016-Dec. 31, 2020.
NOTES: i- Montana is expected to amend its other Section 1115 demonstration waiver to also implement 12-month continuous eligibility for other coverage groups.
ii- Claimed expenditures at the enhanced matching rate will be adjusted downward by 2.6% to account for the fact that the regular matching rate applies to a proportion of expenditures for 12-month continuous eligibility consistent with CMS guidance.
iii- CMS, Special Terms and Conditions, Montana Health and Economic Livelihood Partnership Program Demonstration, Attachment A, Copayment Schedule and Exempt Services (approved Nov. 2, 2015), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mt/mt-HELP-program-ca.pdf.
|Appendix Table 8: New Hampshire’s Section 1115 Medicaid Expansion Demonstration Waiver Provisions|
|Element||New Hampshire Waiver Provision (approved, as amended)|
|Overview:||Uses Medicaid funds to pay Marketplace QHP premiums for all newly eligible adults (estimated 50,000) statewide under the ACA’s Medicaid expansion as of January 2016.
Waiver amendment was approved in January 2017 so beneficiaries above 100% FPL participating in the premium assistance program could be charged different copayments than medically frail beneficiaries above 100% FPL who remain in Medicaid managed care.
|Duration:||3/4/15 to 12/31/18.
QHP coverage effective 1/1/16. From 8/15/14 to 1/1/16, NH covered expansion adults through a traditional ACA expansion with Medicaid managed care plans.
|Coverage Groups:||Newly eligible parents with incomes between 38-138% FPL (non-working) and 47-138% FPL (working) and childless adults ages 19-64 between 0-138% FPL.|
|Exempt Populations:||People with access to cost-effective employer sponsored coverage and those who are medically frail cannot enroll in QHPs.
American Indian/Alaska Natives can opt out of QHP enrollment and receive state plan benefits.
|Enrollment:||QHP enrollment is mandatory for demonstration beneficiaries.
State provides FFS coverage until QHP enrollment is effective.
|QHP Choice and Auto-Assignment:||Beneficiaries will choose between at least 2 silver level QHPs.
Beneficiaries who do not select a QHP within 30 days of their Medicaid eligibility determination will be auto-assigned to a plan. The year 1 auto-assignment methodology will take into account factors such as family affiliation, primary care provider affiliation, and premium costs; state must advise CMS 60 days prior to methodology changes.
|Retroactive Coverage:||Conditional waiver of three months retroactive coverage, to be implemented after CMS determines that retroactive coverage is unnecessary, based on state data showing no gaps in coverage for newly eligible adults prior to their Medicaid application date and upon renewal.|
|Premiums:||State pays monthly premiums directly to QHPs.
Beneficiaries are not responsible for any premium costs.
|Co-payments:||Beneficiaries with incomes below 100% FPL will be enrolled in 100% actuarial value silver plans and have no co-payments.
Beneficiaries from 100-138% FPL will be enrolled in 94% actuarial value silver plans and have co-payments at state plan amounts.
|Benefits:||QHPs provide services in the state’s Medicaid Alternative Benefits Package (ABP) for newly eligible adults.|
|Federally qualified and rural health centers:||Beneficiaries will have access to at least 1 QHP that contracts with at least 1 FQHC or RHC.|
|Prescription drugs:||Limited to QHP formulary. Prior authorization within 72 hours instead of 24 hours.|
|Family planning providers:||State covers out-of-network family planning providers on FFS basis.|
|Wrap-around benefits:||Provided on FFS basis (non-emergency medical transportation, EPSDT for 19 and 20 year olds, family planning services and supplies, and certain limited adult dental and vision services).|
|Oversight:||State Medicaid agency will enter into MOU with QHPs regarding enrollment, payment of premiums and cost-sharing reductions, reporting and data requirements, notices, and audits.|
|Cost-Effectiveness:||May use state-developed tests of cost-effectiveness for premium assistance that differ from those otherwise permissible.|
|Status:||Demonstration approval 3/4/15, amended 1/6/17.|
|SOURCE: N.H. Health Protection Program Premium Assistance, Special Terms and Conditions, #11-W-00298/1, approved March 4, 2015-Dec. 31, 2018.|