| State |
Eligibility |
Benefits |
Cost-sharing |
Financing |
Other Provisions |
|
CALIFORNIA
Waiver application approved by CMS on June 22, 2005
|
N/A |
N/A |
N/A |
• Federal contribution to covering state’s uncompensated care limited to $766 million each year of waiver; state must “earn” $180 million by meeting various benchmarks |
• Funds for years 3 through 5 are tied to creation of a coverage initiative that provides limited benefits to the uninsured |
|
COLORADO
Waiver proposal rejected by the Joint Health and Human Services Committee on August 31, 2005
|
• Restructures Medicaid for the following populations: (1) children with poverty-level family incomes, (2) pregnant women; (3) children in CHP+; and (4) families eligible for Medicaid or CHP+
• Expands Medicaid to: (1) children with incomes between 185-200% of poverty; (2) parents with incomes between 36-60% of poverty; and (3) parents with incomes between 60-100% of poverty (if funding is available)
|
• Core benefits package and wraparound benefit (“Core Plus”) for all
• Oral health carved out of Family Care package; adults not eligible for oral health (except in case of emergencies or accidents)
• Behavioral Health: Basic services currently carved out will be covered under Core benefit
|
No changes |
• Annual increase of capitation rates at 8.4%
• Administrative costs increase by 2.37% every year of the waiver
|
|
|
FLORIDA
Approved by CMS on October 19, 2005
Approved for implementation by the Florida Legislature on December 8, 2005
Waiver enrollment begins in summer 2006
|
• Children, parents, individuals with SSI (but not Medicare), and pregnant women with incomes below 23 percent of poverty must enroll
• Dual eligibles, children with chronic conditions, children in foster care, and developmentally disabled individuals may be required to enroll at a later stage
**First year of waiver demonstration project will occur in Broward and Duval Counties only, with expansion to other counties in the second year, and statewide expansion after evaluation and state legislature’s approval
|
• Risk–adjusted premium paid by state to private plan chosen by Medicaid recipient
• Health plans must provide all mandatory benefits but may decide what optional benefits to cover; plans determine the amount, duration, and scope of virtually all benefits
• EPSDT is preserved for children
|
• Copayments increased for most recipients but remain “nominal”
• Copayments remain the same for kids and pregnant women
• Adults are responsible for all costs above the maximum annual benefit
|
• Per-beneficiary (per-capita) cap |
• Opt out provision for employer-sponsored insurance
• Enhanced Benefits Account: Individuals must exercise personal responsibility and participate in healthy behaviors to “earn” access to account funds; money may be used to pay cost-sharing, non-covered medical expenses, etc.
|
|
GEORGIA
Second concept paper released by the state on May 20, 2005
Process put on hold until 2007
|
• Mandatory populations treated differently from optional populations |
• Medical home model
• Limits access to services
• Eliminates EPSDT
• Eliminates entitlement to nursing home care
• Limits Rx benefits
|
• Sliding scale premiums
• Higher copayments to control utilization
• Higher cost-sharing for optional populations
• Increased Rx copayments
• Cost-sharing differs based on provider quality and cost-effectiveness
|
• Per-capita cap likely |
• Flexible Spending Accounts: Enrollees participating in prevention programs will be rewarded with accounts that may be used to pay for cost-sharing or non-covered benefits |
|
IDAHO
Waiver application submitted to CMS in October 2005
Authorizing legislation signed into law on March 31, 2006
The state subsequently ended efforts to seek a waiver
DRA state plan amendment approved on May 25, 2006 |
• Collapses Medicaid eligibility into three categories: (1) low-income children and working-age adults; (2) disabled individuals and those with special health needs; and (3) elders |
• Low-income adult/children group receives SCHIP-like benefit package with personal health accounts
• No benefit changes planned for disabled individuals or those with special health needs
|
• Premiums and enforceable copayments for the low-income adult/children category |
• No financing details in the proposal |
• Premium assistance program
• Non-public long-term care financing emphasized (reverse mortgages, long-term care partnership programs, revising asset transfer rules)
• Pay for performance
• Expand Medicaid buy-in for workers
|
|
IOWA
Waiver application approved by CMS on July 1, 2005
|
• Expands coverage to: (1) uninsured adults with incomes at or below 200% of poverty and parents of Medicaid or SCHIP kids with incomes at or below 200% of poverty; (2) spend-down pregnant women with incomes at or below 300% of poverty; (3) seriously emotionally disturbed (SED) children |
• Limited benefit package for uninsured adults and spend-down pregnant women
• SED children receive all state plan benefits, targeted case management, respite care, environmental modifications, adaptive devices, in-home family therapy, and family and community support services
|
• Premiums for uninsured adults and pregnant women with incomes: (1) below 100% of poverty— no more than 1/12 of 2% of family’s annual income; (2) 100-200% of poverty—no more than 1/12 of 5% of family’s annual income |
• Annual expenditure cap with growth rate of 7% per year
• Cap may be increased for increased enrollment of SED kids
|
• State agrees to eliminate some inter-governmental transfers (IGTs) as part of waiver agreement
• Service delivery system: Uninsured adults may receive care only at government.-operated acute care teaching hospitals and University of Iowa Hospital and clinics
• Other service delivery requirements for pregnant women expansion
• SED children may obtain services from any Medicaid provider
|
|
KENTUCKY
Waiver application submitted to CMS on November 4, 2005
The state subsequently ended efforts to seek a waiver
DRA state plan amendment approved on May 3, 2006 |
• Waiver applies to all Medicaid recipients except: (1) individuals enrolled in the Passport Health Program; (2) QMBs, SLMBs, QI-1s
• 1915(c) waiver groups would be grandfathered into waiver program
|
Creates four benefit packages: (1) Global Choices: Benchmark plan; for the general Medicaid population
(2) Optimum Choices: Benchmark plan plus intermediate care facility for the mentally retarded (ICF/MR) level of care and current services under the Supports for Community Living waiver
(3) Comprehensive Choices: Benchmark plan plus nursing facility level of care and services previously covered by the Home- and Community-Based Care and Acquired Brain Injury waivers (4) Family Choices: The plan for children currently covered by KCHIP and traditional Medicaid
• “Soft” service limits
• “Soft” prescription drug limit of 4/month (3 brand-name)
• Does not apply to individuals with certain chronic conditions
|
• Copayment amounts increased for all populations
• Annual cap on medical copayments: $225/individual and $350/family
• Annual cap on Rx copayments: $225/individual and $350/family
|
• Per capita caps
• State still negotiating with CMS on waiver financing |
• Get Healthy Accounts: Individuals earn money by participating in healthy practices; account funds may be used to purchase additional health care services, for cost-sharing, etc. |
|
MONTANA
Waiver application submitted to CMS on July 21, 2006 |
• Expands coverage to several populations: (1) individuals covered under the Mental Health Services Plan; (2) uninsured children with family incomes at or below 150% of poverty; (3) seriously emotionally disturbed (SED) children ages 18-20 with family incomes at or below 150% of poverty; (4) working parents with incomes at or below 200% of poverty at the end of Transitional Medical Assistance |
• Adult populations choose from three packages: (1) assistance with monthly premium of employer-sponsored insurance; (2) payment of monthly premium payment for a private insurance plan; or (3) Medicaid individual health care benefit
• Services for expansion groups are limited and capped to benefit package regardless of “medical necessity”
• Child populations receive SCHIP-like benefit package; waives EPSDT
|
• Cost-sharing dependent on which package the individual chooses |
• Per-capita cap
Savings realized from the state’s earlier Section 1115 waiver would be used to ensure this HIFA waiver was budget neutral
|
• Premium Assistance Pilot Program established
• Provides Medicaid funding for portion of Montana Comprehensive Health Authority Premium Assistance program, covering people with incomes at or below 150% of poverty with serious medical conditions who cannot get private insurance
• Provides premium assistance to 1,200 individuals and incentives to small businesses to use health insurance purchasing pool
|
|
SOUTH CAROLINA
Waiver application submitted to CMS on November 16, 2005
|
• All Medicaid populations affected by waiver except dual eligibles and foster children
• People over age of 19, pregnant women, and people with dependent children are considered adults
|
• Risk-adjusted voucher (aka “Personal Health Account”) given to purchase one of the following: (1) self-directed care; (2) private insurance plan; (3) Medical home network; or (4) Medicaid Fee for Service
• EPSDT preserved
|
• All beneficiaries subject to copayments except for children, pregnant women, institutionalized individuals, and home- and community-based services participants
• Annual copayment cap at $250/individual and $400/family
• Copayments enforceable
|
• Per-capita cap |
• Opt out: Individuals with employer-sponsored insurance option may use voucher to purchase coverage
• Self-directed care option: 5,000 enrollees only; may not have acute health care needs
|
|
VERMONT
Approved by CMS on September 28, 2005
Final approval by Vermont Legislature on December 13, 2005
|
• Enrollment can be capped for optional populations
• Eliminates guarantee of coverage for optional populations
|
• No guarantee of mandatory services for optional populations
• No guarantee of optional services for any population
|
• May increase for optional populations and expansion children population, but cannot exceed 5% of family’s gross income |
• Global cap on federal funding (up to $4.7 billion over 5-year period)
• No provision for increase in federal funding if hit by natural disaster, recession, etc
|
|
|
WEST VIRGINIA
Second concept paper released on November 7, 2005
The state subsequently ended efforts to seek a waiver
DRA state plan amendment approved on May 3, 2006 |
• Waiver applies to all Medicaid recipients (except aged and disabled and mentally retarded and developmentally disabled waiver populations)
• Medicaid’s categorical eligibility groups collapsed into four groups (see “Benefits” )
If significant savings are realized from waiver, eligibility may be expanded to childless adults
|
• Offers different benefit packages to each eligibility category: (1) children; (2) adults with children— basic package; (3) adults 65 + – adult services plus services needed to live independently; (4) Special Needs Groups—basic package and home health and nursing home or intermediate care facility for the mentally retarded facility services |
• Increased cost-sharing likely |
• Financing unclear under second concept paper |
• Personal Responsibility Agreements: Require enrollees to commit to participate in prevention activities, like smoking cessation or exercise programs
• Healthy Rewards Accounts: Enrollees receive a set sum of money at the beginning of the year, and their accounts are credited when they engage in wellness or disease management programs; enrollees are penalized if they fail to meet set goals
|
