Medicaid Watch: State Medicaid and Health Cuts & Expansions

Medicaid Watch: State Medicaid and Health Cuts & Expansions May 31, 2013; See pages 11-14 for updated news, sources & resources on state health programs

National Snapshot Summary Cuts or expansions were made or are planned in AL, AZ, CA, CO, CT, DC, FL, 1901 18th St. NW (3rd Fl.) GA, ID, IL, IN, IA, KS, LA, ME, MD, MA, MO, MN, NV, NJ, NM, NC, OH, Washington, DC 20009 OK, OR, PA, SC, TN, TX, UT, VT, VA, WA, WI & WY Virtually all states already pay far-too-low fees to MDs, DDSs, hospitals & Chief Executive Officer: nursing homes and for HCB care and now some are cutting their rates even William E. Arnold more. States with Medicaid Rx numerical limits: AL, AR, CA (grave conditions exception), Phone: (202) 290-2019 GA, IL (HIV exceptions likely), KY, LA, MS, NJ (prop.), NC, OK, PA (prop.), SC, TN Fax: (202) 506-6504 (exceptions for some grave conditions), TX (3 Rx’s/mo cap to be lifted for new HMO plan) & Web: www.tiicann.org WV. Email: [email protected] More & more states deny adults non-emergency dental care & even dentures. 113 are left on ADAP waiting lists in AL & SD. The CR for the last ½ of FY ‘13 Board of Directors lacked $35 million more the Pres. pledged in 2012 & thus 8-15,000 Jeff Bloom clients risked losing coverage; but then HHS “re-programmed” funds to meet Eric Camp the gap Donna Christensen MD MOC State Pharmacy Assistance Programs (SPAPs) in AK, IN, NY, PA, SC & WI Jeff Coudriet (In Memorium) exclude the disabled; and SPAPs in HI, MD, MO, MT & RI give them lesser Wayne A. Duffus MD PhD coverage. Richard Fortenbery GOP Govs., legislators, or both, in AK, AL, GA, ID, IA, KS, LA, MS, MO, NE, NC, NH, Kathie M. Hiers OK, PA, SC, SD, TN, TX, UT & WY are blocking Med. expansion; and even pro- Maurice Hinchey MOC expansion GOP Govs. in AZ, FL, MI, OH & WI face opposed legislative majorities Gary R. Rose, JD Alabama--has no spend down, an aged/disabled level of $710 (SSI’s rate), a parent level of 10%/ Michael J. Sullivan 23% wkg (’12) & a 250% ADAP level; covers only 12 MD visits & hosp days/yr, but has no MSP asset test. The state raised CHIP’s level to 300%. There’s no risk pool low income premium dis- Christos Tsentas count or Medicare supplement. There are 2,500 on the HCB waiver waiting list. Gov Bentley & the Valerie Volpe legislature (both R) cut ADAP’s funds & formulary and MD, DDS, lab & x-ray fees. AL Med. cut Robin T. Webb, DMA Rx funds $30 million & covers only 1 brand Rx/mo (with no limit on generic, mental health & HIV Rx’s). It ended coverage of prosthetics, adult eyeglassses & orthotics. The Gov is considering higher hosp & nursing home assessments, but not more tobacco taxes. There’s an ADAP waiting list of 96

Alaska---this Title XVI state has no spend down; an aged/disabled level of $1,072/mo (its est. SSI/ SSP rate), 74/78% wkg (‘12) for parents, 300% for ADAP, 175% for CHIP, a risk pool with a Me- dicare supplement but no low income discount & a 175% SPAP (that excludes the disabled) level. Gov Parnell & the legislature (both R) refused US grants for an Exchange & to police premiums..

Arizona--has a parent level of 100%/106% wkg & an aged/disabled level of 100%. The CHIP level is 200% & ADAP’s is 300%. The legislature (R) cut MD & personal care fees. Gov Brewer (R) cut ADAP’s formulary, mental health & home care, ended hospice care & kept a CHIP freeze that’s cut enrollment to 18,000—with a waiting list of 100,000 (but CMS is letting hospitals & the state donate funds to enroll 21,000 more). She tried to start/raise co-pays for waiver clients, ended spend downs & coverage of physicals, most adult podiatry, dentistry, transplants (later partially re- lenting) med equip, insulin pumps, hearing aids, cochlear implants & some prostheses. She now

Thomas P. McCormack Editor, MEDICAID WATCH MedicaidWatch - supported by unrestricted educational grants from ViiV Healthcare, Abbott Laboratories, Amgen, Gilead Sciences, Merck & Co., Bristol Myers Squibb, Boehringer Ingelheim & Janssen Therapeutics seeks more US aid to extend---and no longer to end—a waiver covering 250,000 childless, non- non-disabled adults & even wants to expand Medicaid.

Arkansas—has an aged/disabled level of $710 (the SSI rate), a parent level of 13%/16% wkg (’12), a monthly numerical Rx limit & an insurance subsidy for small firm workers below 200%, which Gov. Beebe (D) has proposed dropping. The legislature (D in 2012; but R in 2013) covered adult dentistry & passed an at-first unfunded bill to raise CHIP’s level from 200 to 250%. The risk pool bars Medicare patients. He may cut the number of covered MD visits & Rx’s; and drop coverage of adult non-emergency dentistry & low level nursing home care; and cut ADAP’s formulary & its income level from 500 to 200%. He favors Medicaid expansion & offered a compromise to cover new expansion eligibles (even the childless, non- disabled) under 138%) with state-subsidized/purchased private insurance instead of outright “Medicaid“ itself, which the GOP legislature accepted.

California-- covers the aged/disabled under 100% (with a $230, not just a $20, disregard) & parents below 100/106% wkg. ADAP’s level is 400% & CHIP’s is 250%. To cut a big deficit, the legislature (D) raised premiums; capped child dentistry at $1,500-$1,800 yr; cut podiatry & psychiatric benefits; denied non-emergency care to legal aliens; cut provider fees; and denied ADAP to county jail inmates. Gov Brown (D) signed bills cutting “non-life-saving” Rx’s to 6/ mo, MD visits to 7/ yr & MD fees by 10%; and some personal aide services for the disabled. A $300 million LA Co Health Dept deficit may cut patients seen by 25 to 50%. Courts barred ending a- dult podiatry, chiropractic & dentistry. Brown cut CHIP & home, mental health & DD care funds; added $77 million to ADAP (but imposed up to $400/mo cost-sharing on wealthier patients); started covering the childless, non-disabled under county-set levels (200% in 50 counties, 133% in 5) to US-matched Medicaid (e-mail adonnelly @projectinform.org for details); but the Supreme Court reman- ded a suit to bar 10% provider fee cuts back to the 9th Circ & a court settlement saved some of the adult day care budget from cuts

Colorado---has no spend down. The level for those over 60 is $735 (their est. SSI+ SSP rate), but it’s only $710/ mo (the SSI-only rate) for younger disabled. ADAP ‘s level is 400%. The risk pool has low income premium discounts for those below $50,000 & Med- icare supplements. The state set up a Medicaid formulary, made health plans cover PTSD, anorexia, substance abuse & colorectal screening, and expanded ADAP’s formulary and its program to pay insurance premiums for HIV+ clients. The 2010 legislature (D) passed a $600 million hospital tax for Medicaid, CHIP & the state indigent health program; to boost hospital rates & uncompensated care funds; and to cover 100,000 more persons by raising levels for all adults to 100% (it now covers parents to 100/106% wkg; but the coverage also promised to childless, non-disabled adults was later cut from 100% to only 10% & limited to only 10,000 patients); applied the mini-COBRA law to small firms; raised CHIP’s level from 205 to 250% & widened its psychiatric care; offered Medicaid to the working disabled; covered legal aliens; set a 300% level for nursing home & HCB waivers (with liberal HCB, personal aide & client autonomy features). Advocates say the 300% FOA level is too low to cover enough disabled children, premiums are too high & the state limits how many to cover. It cut funds for DD & disabled clients’ employment, patient transportation & personal aide pay, but raised the pregnant woman level from 133 to 185%. Gov Hickenlooper & the legislature (now D) campaigned for more health coverage, but instead made big cuts (he & the Sen. even gave in to demands by 2012’s GOP House to raise CHIP premiums & co-pays) Connecticut—a 209(b) state with 2-zone aged/disabled levels ($786.22 & $894.61, its est. SSI/SSP rates for those with over $400/mo shelter costs & including a $278/mo disregard). Its parent level is 185%/191% wkg; ADAP’s is 400%; and CHIP’s is 300%. Its risk pool has low income premium discounts for those under 200% & a Medicare supplement. Ex-Gov Rell (R) ended coverage of legal aliens here under 5 years. There’s no MSP asset test & the disabled’s SPAP income levels are $25,100 for 1& $33,800 for 2. She limited adult chiropractor, naturopath, psychologist and occu, phys & speech therapy coverage to clinics; but offered hospice care to all Medicaid patients. The legislature (D) covered the working disabled. Rell created a skimpy subsidized insurance plan for parents under 306% & other adults under 310%, but its quickly escalating costs rose so fast & high that premium subsidies have had to be slashed. It has big co-pays, limited psychiatric care, low caps on Rx’s, medical equip & total yearly costs plus a $1 million lifetime cap. CMS provides matching to give Medicaid to childless, non-disabled adults under 56% who were on State Gen Med Asst to (keep- ing a $150/mo earnings disregard). The state extended COBRA to 30 mos, and raised QMB’s level to $1779.68/ mo, SLMB’s to $1,961.28 & QI’s to $2091.67 (giving them full Pt D Extra Help too, thus letting the state drop many on Medicare from the SPAP — while still covering the disabled during their 2 yr Medicare wait). Gov. Malloy is (D) moving 2,200 patients from nursing homes into home or HCB care and cancelling managed care contracts. He cut respite; adult dental & vision benefits; and low income clinic funding $3.8 million; and even proposes to lower the current, pre-Jan. 2014 CHIP/ Medicaid level for parents from 185 to 133%

Delaware---has no spend down; a waiver covers parents under 100%/106% wkg & other adults (even the childless, non-disabled) under 100/110% wkg. The ADAP level is 500% and those for CHIP & the SPAP are 200%. Gov. Markell & the legislature (both D) run a state-funded cancer aid program for those under 650% & state-funded medical assistance (more limited than Medicaid) for others under 200%, covered the wkg disabled; but ended adult vision care and may even have to drop speech, physical & occu therapy District of Columbia--has parent levels of 200%/206% wkg, 100% for aged/disabled, 300% for CHIP & 400% for ADAP. The Coun- cil (D) covered adult dentistry; raised QMB’s level to 300%, (with no asset test, so many DC Medicare patients now get full Pt D Ext- ra Help), but ex-Mayor Fenty (D) proposed replacing public mental health clinic care with private contractors; cut MD fees for dual & QMB eligibles and funds for home care & personal aides. Mayor Gray (D) extended Medicaid to all adults (even the childless, non- disabled) below 200/211% wkg with now-available Medicaid matching (any others under 200% can get on DC’s local Alliance plan)

2 Florida---The legislature (R) got a waiver to move patients (a court order had let them opt out) into managed care; but at first it did so in only 5 counties, but it’s been expanding it statewide (to be completed by late 2014). It includes the aged & disabled, as well as families & children. HHS approved the plan— but only if 85% of premiums go to care & quality upgrades and plans meet the needs of 98.5% of patients & cost sharing is kept below regular Medicaid ceilings. Email [email protected] for details. The legislature & Gov. Scott (both R) planned to cut MD fees & did cut the aged/disabled level from 88% to SSI’s $710 mo rate, except for those in HCB waiver care (with 300% levels), or in Medicare’s 2 yr disabled waiting period (who are still covered up to 88%). The parent level is 18%/ 56% wkg (‘12) & CHIP’s is 300%. The state covers dentures (but little other adult dentistry), hearing aids & some autism care. Blue Cross & Dade Co. sponsor cheap & lean “Miami-Dade Blue” policies that don’t cover brand Rx’s for the low income uninsured and Palm Beach Co. subsidizes insurance for those under 300%. Ex-Gov Crist (then R, now D) dropped hospice care and cut dialysis, mental health & substance abuse funds and MD fees. There are 19,000 on HCB & home care waiting lists & advocates sued to force more such spending, yet a GOP-run legislative panel refused $37 million more in US funds to increase HCB slots. Crist made insurers sell Medigap policies nearly as fairly to the disabled as to the aged. Jackson Mem Hosp closed 2 O/P clinics & 2 transplant units and ended dialysis for 175 indigents (many of them illegals). ADAP cut its formulary, but has no asset test & a 400% income level. Scott chose a panel to cut or end the 20 state hospital districts’ taxes that help pay the state Medicaid matching share, and seeks big hospital rate cuts. He signed a bill shifting most of $325 million in unpaid Medicaid costs to the counties. A US Dist Court told the state to cover more autism care, but it may appeal. Some families say the state is cutting paid hours for home care of the disabled.

Georgia---Its aged/disabled level is $710/mo (the SSI rate), its parent level is 27%/48% wkg (‘12), ADAP’s is 300% & CHIP’s is 235%. It has a monthly Rx numerical cap. It dropped CHIP dental surgery & raised its premiums; ended routine adult dental & artifi- cial limb coverage and nursing home spend downs; and narrowed Katie Beckett waiver admission rules. Atlanta’s Grady Hosp, with a big deficit from indigent care costs, closed its dialysis center & 3 of its O/P clinics and cut its free care level to 125% from 250%. The legislature (R) won’t raise provider fees & cut ADAP $1.2 million. MD & DDS fees were cut; it sought more insurance taxes & fines for health costs, closed a mental hosp building, cut pregnancy & infant care funds; imposed ADAP medical qualification rules; and proposed privatizing some mental health care. With a large Medicaid shortfall, Gov Deal (R) wants more cuts (i.e., ending adult podiatry, vision & emergency dentistry,but which the House voted to retain); signed a bill requiring new hosp taxes to bolster Medicaid and sought to raise adults’ O/P co-pays to 15% & their I/P hosp co-pays by 400%, and even charge children co-pays for the 1st time.

Hawaii—this 209(b) state gives limited Medicaid waiver care to all adults below 133% (even the childless & non-disabled) but only parents & children and the aged & disabled under 100% get full Medicaid Its ADAP level is 400%. It covers the wkg disabled. The legislature (D) raised CHIP’s level to 300% & dropped its premiums. The state is moving 37,000 aged & disabled into managed care, ended non-emergency adult dentistry & planned even more cuts for non-pregnant & non-disabled adults. Gov Abercrombie (D). is es- tablishing a voluntary-for-providers Medicaid “medical home model”, but reluctantly cut Medicaid $25 million in FY ‘12 & $50 million for FY ‘13; and limits non-disabled, non-aged adults to 20 MD visits a year, 10 hospital days a year (which CMS forced the state to lengthen to 30, with full exemptions for children, the pregnant, the blind & cancer patients) & 3 outpatient surgeries a year.

Idaho--is a Title XVI state, with no spend down, an aged/disabled level of $780 (the est. SSI/SSP rate), a parent level of 20%/ 37% wkg (‘12) & a 200% ADAP level. The legislature (R) raised CHIP’s level to 185%; funds a pilot plan for small firm workers under 185%, covered the wkg disabled & sorted clients into 3 groups: Parents & children; disabled & chronic cases; and the aged. Each may get varying benefits or co-pays but more preventive care. Gov Otter (R) charges 4% of income premiums to Katie Becket waiver families & may charge other disabled children extra premiums too; he cut hosp, MD, rehab facility & DD agency fees (which a court barred temporarily), occu & speech therapy and autism funds; but its ADAP waiting list numbers 14 and there’s an enrollment cap. Otter and the legislature plan Medicaid cuts of $34 million: more & bigger co-pays; lower Rx fees; audiology, vision, podiatry and mental health cuts; limiting adult dental care; more use of managed care; and levying a $7.5 million hospital & nursing home “assessment”

Illinois--this 209(b) state’s aged/disabled level is 100% (with a $25, not just a $20, disregard). The legislature (D) accepted a court order to raise pediatric fees. But other fees are too low & paid very late, with a $2 billion unpaid claims backlog as of April, 2013. It earlier raised CHIP’s level from 200 to 300%. The often-closed state risk pool has a Medicare supplement but no low income premium discount (yet the now-closed separate US health reform-funded risk pool premiums were affordable for many under 40). The state raised the wkg disabled level to 350% and required that Medigap policies be sold as fairly to the disabled as to the aged. The U of Chi- cago Med Ctr closed women’s & dental clinics; the U of IL at Chicago closed a clinic too. The state gave $640 million to safety net hospitals, made hospitals give the uninsured discounts & “assessed” them to attract $450 million more in US matching. Gov Quinn (D) & the legislature raised income taxes 2.25%, boosted some other taxes, added a $1-a-pack to the cigarette tax & mandated more client income verification; are forcing 1/2 of clients (mostly parents & children) into managed care (plus 40,000 aged & disabled in Chicago suburbs); and cut Rx fees $42 million. The state imposed a 4 Rx’s per month limit for adults (exempting HIV cases, but with an unwieldy exception process for others that’s causing many to flood ERs to get Rx’s, ,riling MD & advocacy groups); tightened a gene-rics preference rule; imposed pre-authorization for 17 costly psychiatric Rx’s; and dropped benzodiazepine coverage. Quinn hopes to save $400 million more with aged & disabled case management (38,000 are already on HCB waiting lists). He gave $30 million more to low income clinics & ADAP enough money to cover 4,500 more clients (with a $2,000 /mo per client cap). But a $1.5 million budget cut reduced ADAP’s level from 500 to 300% (grandfathering-in current clients). Then Quinn sought a further $4.7 million ADAP cut and legislature cut Medicaid $1.6 billion more; closed 2 DD centers & 2 mental hospitals; abolished both SPAPs 3 (with 180,000 clients); cut the parent level from 185 to 133% (dropping 26,000;, limited chiropractic care; ended non-emergency a- dult dentistry, podiatry for non-diabetics & elective C-sections; and cut non-MD fees (sparing some safety net hospitals). IL got a Me- dicaid waiver to cover all adults (even the childless, non-disabled) under 138%--but only in Cook Co & only for care at the Cook Co. Hospital network & at FQHCs. Advocates had sought to make the expansion statewide at once ( before 1/1/14) but the legislature dissapointingly voted to wait to do so until 1/1/14---as already planned anyway. The state added $3.5 million more to ADAP.

Indiana--this 209(b) state’s SPAP (for which a state law passed in 6/11 now seeks US matching to help fund it as a waiver) covers those under 150% but excludes the disabled. The state also has a much-stricter-than-SSI “209(b)” Medicaid disability rule (one must be fatally or incurably ill). The aged/disabled level is $710, (the SSI rate) & the regular Medicaid parent level is 18%/24% wkg (‘12). Ex- Gov Daniels & the legislature (both R) raised CHIP premiums. The pre-health reform state risk pool has a Medicare supplement & a low income premium discount. The ACLU sued to void a once-ea-6-yrs denture replacement & re-lining limit and the legislature was considering a once-ea-5-yrs eyeglass replacing limit. ADAP has a 300% level & an enrollment cap; but 21,000 DD clients are already on a HCB waiver waiting list, yet Daniels raised CHIP’s level from 200 to 300%. A waiver subsidizes coverage for parents below 200/ 250% wkg & even has 14,000 slots for the childless, non-disabled (but with 52,000 more on a waiting list when enrollment was closed). State GOP leaders have always opposed the ACA & state or hybrid Exchanges, yet they’ve toyed with trying to use new US health reform matching to fund the waiver & cover all non-Medicare adults (even the childless, non-disabled) under 138% by, or even before, 2014--but only if HSA’s & more cost-sharing are allowed. CMS rejected this proposal, but GOP legislators & Gov. Pence (R) insist on CMS allowing these as at least part of their price in exchange for expanding Medicaid to 138%. The waiver uses HMOs with no dental, vision or maternity coverage. Patients must put 2%-5% of income into HSAs, pay very steep premiums & meet $1100/yr in cost-sharing. It has $300,000 yearly & $1 million lifetime benefit caps. The state had planned to cut hosp nursing home & other provider fees 5%. The State Supreme Ct rejected a suit to make the state consider more conditions in Me- dicaid disability eligibility decisions. Budget cuts will end or limit adult dental, vision, chiropractic & podiatry benefits. IN tightened its psychiatric Rx formulary & a US Dist Ct dismissed a suit to bar Rx fee cuts. The US 7th Circuit Ct voided the state’s dental fee cap

Iowa--A waiver covers both O/P & emergency I/P care for non-Medicare adults (even if childless & non-disabled) under 200% /250% wkg at any Iowa public or low income clinic or hospital (but Rx’s “to go” & elective I/P hospitalization are covered only at 2 Des Moines & Iowa City safety net hospitals—and the O/P drugs they dispense are provided not by Medicaid but by hospitals’ own charity budgets and/or drug-makers’ PAPs). The aged/disabled level is $710/mo (the SSI rate), the parent level is 27%/80% wkg (‘12) & ADAP’s is 300%. The risk pool has a Medicare supplement but no low income premium discount. Medicaid faces a $600 million deficit. Ex-Gov. Culver & the 2012 legislature (both D) covered disabled children under 300% via the FOA, raised CHIP’s level from 200 to 300% & let children with no dental coverage buy into CHIP dental benefits. The hospitals proposed taxing themselves $40 million to attract added US matching to raise their rates & pay other costs. Gov. Branstad & the House (both now R) plan to cut Medic- aid (e.g., ending chiropractic care, raising co-pays & requiring pre-authorization for more services); and the Senate (still D) even ag- reed to Branstad’s budget (yet it did vote to make the US-funded and/or the state’s own risk pool more accessible to HIV clients). The state got an extra $60 million US grant to expand HCB & other home care as cheaper alternatives to costlier nursing home care.

Kansas---this Title XVI state has an aged/disabled level of $710/mo (SSI’s rate), a parent level of 25%/31 wkg (‘12), and a 300% ADAP level. Its GOP legislature covered the wkg disabled, offered mini-COBRA rights and raised CHIP’s level to 250%. About 3,000 physically disabled & DD clients are on waiting lists for services, yet the state cut home care funds for the aged & disabled, MD fees and the disabled’s caregiver pay, denied dentistry to poor women; raised CHIP premiums to $20/mo; and froze admissions to state mental hospitals. Gov. Brownback (R) slashed Aging Department personnel costs 25%, cut mental health funds $25 million, proposed ending therapy for 850 troubled children and told his Lt. Gov. to plan Medicaid cuts of $200 to $400 million yr (e.g., by forcing the aged & disabled into HMOs), but public protests forced him to delay forced enrollment of DD clients for at least a year. . Kentucky--- has an aged/disabled level of $710/mo (the SSI rate), a parent level of 33%/57% wkg (’12) and 200% CHIP & ADAP levels. The legislature (R Sen; D House) dropped tough, unworkable nursing home & HCB medical admission rules; capped Rx’s at 4/mo, cut home teaching funds for blind children; limited occu, phys & speech therapy, x-rays & MRIs; and raised co-pays. Gov Beshear (D) faced a Medicaid/CHIP deficit of up to $500 million, yet still enrolled 22,000 more children in CHIP & dropped its $20/mo premium. ADAP has co-pays & its formulary was cut. After both the Senate (R) and the House (D) spurned his budget for a GOP plan, he line-item vetoed their bill. Now he is implementing his own Medicaid budget plan to save $375 million in state funds by moving 560,000 of 820,000 non-Louisville-area clients into 3 HMOs (170,000 in the Louisville area are already in an HMO).

Louisiana---has an aged/disabled level of $710/mo (the SSI rate), a parent level of 11%/24% wkg (‘12) & a 300% ADAP level. The legislature (R) voted to raise the CHIP 250% level to 300% but can’t afford to. Gov Jindal (R) covered the wkg disabled & got CMS to agree to a state refund of only $266 million of much more in past overpayments to it. He found $30 million/yr for clinic funding when US funds weren’t renewed & CMS even let him spend $97.3 million in US Medicaid hospital funds on O/P clinics. He wants to save $268 million by cutting covered Rx’s from 8 to 5/mo (unless more are “medically justified”); MD & hospital rates and privatizing community services & HCB care. He plans to put almost all patients into 5 CCOs. US matching fell $700 million & 2012’s deficit rose to $1.5 billion. But clauses Sen. Landrieu (D) put in the ACA & in later laws---all of which critics dubbed a “2nd LA. Purchase”---gave the state $ 1.7 billion more from FYs ’11 to ’14 over its normal matching rate, which was subsequently cut by $400 4 mil-lion by GOP Congressional leaders—and it will fall further because CMS seeks return of still another $859 million in alleged over-payments Jindal, the legislature & the Charity Hosp board cut $859 million more of their state funds. FEMA is paying $478 million to re-build the New Orleans Charity Hosp, to which the state is to add $300 million (but it needs $70-$100 million more a year to run it). The Gov wants a $62 million cut for LSU’s Hospitals (even though the state already lacks enough funds to run 4 to 6 LSU & Char-ity Hospitals), dropped plans to end Medicaid hospice coverage, yet cut speech & phys therapy and other benefits. A waiver offers pri-mary care to all adults under 200% (even the childless, non-disabled) in Orleans, Jefferson, St. Bernard & Plaquemines Parishes.

Maine—until now, has had these income levels: subsidized insurance, 300% ; the aged & disabled, 100% (with a $75, not just a $20, disregard for both Medicaid & the MSPs); childless, non-disabled adults, 100% (via a waiver now closed to new applicants); parents, 200%/206% wkg (’12); ADAP, 500%; CHIP, 200%; the SPAP, $1,604/ mo for 1 & $2,159/ mo for 2; and 250% for O/P-only waiver care for HIV+ (even “pre-disabled”) patients. Adults get dentures but little other dentistry. The QMB income level is 150%, SLMB’s, is 170% & QI’s is 185%--all 3 of which Gov. LePage (R) proposes to reduce. He raised cost-sharing for those over 150%, and cut podiat-ry care & provider fees. He & the 2012 GOP legislature (it’s again D in 2013) sought HHS approval for the waiver to drop 16,000 -–even with 14,000 more on a waiting list—of the childless, non-disabled , plus 19 & 20-yr-olds; (see “Preserving Maine- Care Cover-age of [Poor Non- Disabled, Childless] Adults..” at www.mejp.org), even before its scheduled expiration ), and also to drop 12,000 parents by cutting their 200% level to 133%. On 3/1/13 HHS let him do that & drop coverage of the childless, non-dis- able too. He also plans big cuts in cancer screening, covered hosp days & O/P care; and dropped coverage of legal aliens in the US less than 5 yrs The hospitals are demanding payment of $186 million that they say is owed them for care from as far back as 2009.

Maryland---has an aged/disabled level of only $710/mo (the SSI rate), a 300% CHIP level & a 500% ADAP level. An appeals court upheld an AARP/Legal Aid suit to widen the state’s too-strict nursing home, HCB waiver & at-home care medical qualification & appeal rules. A waiver merged the main SPAP & a low income O/P clinic program into one O/P-only primary clinic care & Rx program for non-Medicare adults (even if childless & non-disabled) under 116%/ 122% wkg. A state-sponsored, Blue Cross-run 2nd SPAP (with a 300% level) covers some Medicare Pt D donut hole & premium costs, but it seems to exclude the disabled. The risk pool has low income premium discounts for those under 200% but no Medicare supplement. Gov O’Malley & the legislature (both D) covered the wkg disabled, raised the parent Medicaid level to 116/122% wkg, plan to soon phase in full Medicaid for childless, non-disabled adults under 116/122% wkg and subsidizes insurance for some low paid small firm workers. He cut $82 million in nursing home, home health aide, private RN & HMO fees and slashed hospital rates to 80% of private plans’. He also cut other providers’, HCB programs’ & the disabled’s personal aide fees. He & the nursing homes hope to more than make up their fee cuts with later rate raises funded by a 2% tax they’ll pay to be used to attract more US matching. He’s considering a $150-$264 million hospital “assessment” to draw in more US matching to use to raise their rates & for other Medicaid costs. He’s raising child dental fees & carving child dentistry out of HMO contracts; made hospitals give free care to those under 150%; and got the legislature to raise taxes on the wealthy.

Massachusetts---In 2006, ex-Gov. Romney (R) & the legislature (D) required all adults to have insurance, subsidized it for those under 300% & boosted the CHIP level from 200 to 300% (and a state program started about 1990 also offers CHIP-like coverage to children under 400%). The parent and childless aged, disabled & non-disabled adult Medicaid levels were raised to 133%. The ADAP level is 500% & the SPAP’s is 188% (but up to 500% for Pt D patients). Gov. Patrick (D) raised subsidized insurance & Medicaid MD visit & Rx co-pays from $2 to $3; boosted SPAP cost-sharing; froze MD & hospital fees; and cut public health funds. The legislature got him to delay adult day health program cuts until after 2011; grandfathered-in undocumented aliens getting insurance subsidies & Medicaid since before 8/09 to only limited benefits; and reduced adults’ Medicaid & subsidized insurance dentistry to emergency & preventive care and cut covered hospital days to 20/yr. To control costs more, he wants to shift to Accountable Care Organizations (ACOs) to pay for wellness & treatment results rather than fee-for-service rates that now drive costs too high. CMS approved a waiver add-on to give nearly $500 million to some metro & safety net hospitals and a waiver to give the state $26.7 million more for its health reform plan. The state’s highest court ordered it to again give Medicaid to legal aliens here under 5 years, even without US matching.

Michigan---has a 100% aged/disabled level, a parent level of 37%/64% wkg (‘12), a 200% CHIP level & a 450% ADAP level. It ended adult hearing aid & chiropractic coverage but has a now-closed O/P care-only waiver for childless, non-disabled adults under 35% / 45% wkg. The legislature raised co-pays but boosted child wellness and dental & adult preventive fees. The Lansing-, Muskegon-, Detroit- & Flint-area counties offer free/cheap coverage to those under 200%-- but, with funds short, Flint’s Genessee Co may close enrollment. The House (then D, now R) & Senate (still R) restored adult dental, vision & podiatry (but not hearing aid or chiropractic) care and made no MD & hospital—and few mental health--cuts. Gov Snyder (R) pledged to make no cuts but then cut teaching hospitals $67 million & Medicaid agency costs $21 million. He began moving dual eligibles into HMOs and --say advocates--cut home chore aid so much as to harm de-institutionalization efforts (thus risking inflating nursing home costs even more); and dropped 11,000 TANF welfare cases (but says they’ll still get Medicaid). The state may replace an HMO tax—which CMS disallowed--with a low tax on all HMO and insurer claims to prevent a $400 million Medicaid loss and announced that it’s starting coverage for autism care.

Minnesota---this 209(b) state has an aged/disabled level of 100%, a parent level of 275% wkg or not, a CHIP level of 275%, an ADAP level of 300% & a risk pool with low income premium discounts for those under 200% & a Medicare supplement. The state raised Medicaid, CHIP & MinnesotaCare (state-subsidized insurance for childless, non-disabled adults below 200%) premiums & 5 co-pays and denied Medicaid & CHIP to legal aliens. The state capped enrollment in HCB care, tightened its medical qualifications for & slashed paid hours for home aides; cut nursing home & HCB waiver fees; raised some premiums; and dropped speech & occu therapy, audiology & adult dentistry. Gov Dayton (D) expanded US-matched Medicaid to cover previously state-funded General Med- ical Assistance (GMA) patients under 75%. He & the outgoing GOP legislature (which became D again in 2013) compromised: He dropped his proposed “millionaire”, hospital & nursing home taxes & accepted repeal of certain provider taxes that had been spent on MinnesotaCare and they funded the 100,000+ of the MinnesotaCare & GMA patients he added to Medicaid. The old GOP legislature forced him to make $400 million in provider fee & other cuts. The Medicaid agency said it will cover only ER & I/P hospital care for non-citizens and will begin denying them formerly-covered dialysis, chemotherapy, O/P prescriptions, dentistry & mental health care

Mississippi---has no spend down. Ex-Gov. Barbour (R) cut the aged/disabled level from over $1,000 to $724/mo (with a $50, not just a $20, disregard), with no asset tests (including for MSPs). The parent level is 23%/29 wkg (‘12), CHIP’s is 200% & ADAP’s is 400% Only 2 brand name Rx’s/mo & 3 generics/mo are covered (but HIV patients get 5 brand name Rx’s). Barbour cut phys, speech & occu therapy benefits. An in-person re-application rule limits enrollment; the Senate (R) won’t drop it, except maybe for LTC, but the House (also R) might. After securing new cigarette & hosp taxes, Barbour proposed DDS, nursing home & hosp (but not MD) fee cuts as well as patient premiums & higher co-pays; a 7% mental health cut, lower mental health center subsidies and closing 4 mental hospitals & 15 mental crisis centers. Some disabled children’s parents complain that the state tightened Katie Becket waiver medical qualification rules. Gov. Bryant (R) plans to award contracts to what some advocates say are favored, but sub-par, managed care firms

Missouri---is a 209(b) state. Its risk pool has no Medicare supplement but has a low income premium discount. The GOP legislature cut the aged/disabled level from 100 to 85%; ended medical aid for those awaiting SSA disability awards; cut the 100% parent level to 18%/ 38% wkg (‘12); raised CHIP premiums; denied CHIP to those whose job plans cost under 5% of income; raised & more strictly enforced co-pays; kept the ADAP & CHIP levels at 300% & raised the SPAP level (it’s only for Medicare patients) to 150%. The state pays clients’ job plan premiums; restored hospice & wkg disabled coverage (but the latter covers only those with very low SSDI checks); gives birth control & screenings to women under 185%; restored adult vision (except for the nursing home aged), hearing aid & podiatry benefits; and let the aged & disabled opt out of HMOs .A court made the state widen notice & hearing rights before closing CHIP cases The state let community health & rural clinics presumptively enroll children in Medicaid & CHIP (before, only 4 hospitals could). Gov. Nixon (D) sought hospital rate cuts of $139 million and $32 million in MD & DDS fees and mental health & public clinic funding. He had to drop his plans to restore prior parent & aged/disabled income levels. MO covers dental care only for children, the blind & the pregnant; and it made private plans cover some autism care. CMS said the state wrongly limits home health care to the homebound; and state & CMS staff learned that the aged/disabled spend down was being calculated too liberally (by letting clients deduct disallowed paid & written-off bills). A local non-profit subsidizes care (only for O/P care & generic Rx’s) at low income clinics with DSH funds from a closed public hospital, for all adults (even the childless, non-disabled) under 133% in St. Louis City & County. This basic “Gateway” plan also pays for specialist care at academic health centers if unavailable at the clinics, while a “Silver” adjunct plan does so for other clinic patients with incomes up to 200%. I/P care is covered by hospitals’ Hill-Burton or other in-house charity programs, while drug makers’ own corporate patient assistance programs (PAPs) provide brand name prescriptions.

Montana---has an aged/disabled level of $710/mo (the SSI rate), a parent level of 31%/54% wkg (‘12), an ADAP level of 330% and a risk pool with low income premium discounts for those under 150% & a Medicare supplement. It raised cost-sharing and cut LTC & hospice benefits & access—and even limited aged & disabled MD visits to 10/yr. But ex-Gov Schweitzer, Gov Bullock (both D) & the legislature (R) did end an ADAP waiting list. They raised the family asset level; started a SPAP for aged (but not disabled) Medi- care patients under 200%; widened CHIP dental & preventive care; made private plans cover vaccinations & well-child care to age 7; raised CHIP’s level to 250% yet cut provider fees 6%. The legislature also voted to study privatizing the Medicaid agency itself.

Nebraska---is a Title XVI state with a one house, non-partisan, but conservative, legislature. Its aged/disabled level is 100%, its parent level is 47%/58% if wkg (‘12) & ADAP’s is 200%. It ended Medicaid for many parents who got off welfare to work, yet the state Supreme Ct barred denying it to those who don’t meet work mandates. The risk pool has a Medicare supplement but no low income premium discount. Gov. Heineman (R) raised CHIP’s 185% level to 200% but cut non-primary care fees 5%, raised co-pays; and may limit dental care to $1,000/yr, hearing aids to 1 ea 4 yrs, eyeglasses to 1 ea 2 yrs and adults to 12 chiropractic visits & 60 occu, speech & physical therapy sessions/yr. ADAP’s formulary was cut .The legislature reversed its earlier exclusion of all pregnant aliens from coverage, (over-riding Heineman’s veto) & widened school health services. He proposed dropping those who don’t meet a new work rule. The legislature also overrode his veto of a nursing homes-backed bill to tax themselves enough to attract more matching to use to then raise their rates. He plans cuts in home care & private duty nursing funds, and in the number of covered mental health visits.

Nevada—a Title XVI state with no spend down; its disabled level is only $710/mo (the SSI-only rate), but the aged level is $746.40 (because of the est. SSP they get too); its parent level is 24/84% wkg (‘12); CHIP’s is 200%, ADAP’s is 400% & the SPAP’s (which covers the disabled & even has a vision benefit) is 225%. It subsidizes insurance for small firm-employed parents under 200% & covers the wkg disabled. But the state raised CHIP premiums, capped CHIP dental care at $600/yr; ended Medicaid adult dental & vision care and CHIP orthodontia; tightened SNF, ICF, HCB waiver & home care medical qualifications; and cut pregnancy coverage, It cut hosp rates (closing the U of NV at LV Hosp’s dialysis & oncology units), HCB waiver fees & the disabled’s attendant pay; and non- emergency transport, hosp neonatal, HCB waiver & pediatric specialist fees. It set up a formulary for anti-psychotic, anti-convulsant 6 & diabetic Rx’s. Gov Sandoval (R) sought a $500 million Medicaid cut: slashing Rx costs $104 million, mental health care $60 million & other provider fees 15%-43% and imposing co-pays for the 1st time on many services (especially on “unnecessary” ER visits). Relevant committees of the legislature (D) & the State Supreme Ct overturned $88 million of his SNF, ICF, hospital & MD fee cuts.

New Hampshire---a 209(b) state; its risk pool has no Medicare supplement but has low income premium discounts for those under 250%. Its aged/disabled level is $737 (the est. SSI/SSP rate, with a disregard of only $13/mo). The parent level is 38/47% wkg (‘12); and CHIP’s & ADAP’s are 300%. It has a stricter-than-SSI “209(b)” Medicaid disability rule (inability to work for over 4 years) & doesn’t cover hospices. The legislature (both Houses R in 2012, but the House is D in 2013) shifted nursing home costs to counties, but ended a DD care waiting list; yet plan more provider fee cuts. The state’s moving more patients into HMOs and slashed aged/disabled board & care home casework funds $1 million. The 2012 legislature tried, but failed, to cut $230 million in hospital taxes (that Gov Hassan (D) favors ) which yield sufficient funds to attract enough added US matching to meet their shortfalls from too-low fees

New Jersey---has an aged/disabled level of 100%; a 500% ADAP level & SPAP levels of $31,850 for 1 & $36,791 for 2. A waiver covers 70,000 childless, non-disabled adults with income under $210/ mo. The state has a waiver covering parents under 200% & ended CHIP premiums for those below 200% (but cut CHIP’s income level to 350%). It reduced hospital charity funding, raised the SPAP’s co-pays & cut its formulary. Gov. Christie (R) sought to drop coverage of legal aliens & township indigent care funding. The legislature (D) opposes his $3 adult daycare co-pay proposaal & ending the SPAP’s Pt D wraparound & co-pay coverage. He continues to re- ject US birth control, obstetrics and cervical breast cancer screening funds; vetoed a family planning bill; proposes to impose more client cost-sharing; and got a 2nd “comprehensive” CMS waiver to save $300 million (Google “New Jersey Concept Paper” for details; note that he dropped his original proposal to cut the parent level to even below 133%), including savings by moving the rest of the aged & disabled--many of them still in fee-for-service care---into managed care (even for nursing home, HCB, Rx, home health, adult day health care & personal aide care); and cuts of $8 million to women’s health, plus $9 million in mental health. Once promised higher rates, nursing homes now face 6%-8% cuts from a series of measures Christie approved; and he’s even considering limiting the number of covered Rx’s. CMS says NJ owes it $50-$100 million for past wrongly-claimed matching for sub-par personal care

New Mexico—has no spend down, but has a risk pool with a Medicare supplement & low income premium discounts for those under 400%. Its aged/disabled level is only $710/mo (the SSI rate), its parent level is 28%/85% if wkg (‘12), CHIP’s is 235% & ADAP’s is 400%. A waiver—again closed to new individual applicants, but not to small employer groups--subsidizes insurance of almost any adult (even if childless or non-disabled) under 200%/250% if wkg. The state won’t take disability-based Medicaid-only applications of those whose disability hasn’t yet been approved by SSA---no matter how much they need immediate care. With a Medicaid shortfall of $300 million the state may end adult dental, vision, hearing aid & hospice coverage; slash phys, occu & speech therapy; cut mental health & substance abuse care & fees; and may cut some Rx benefits & HCB care. Gov. Martinez’ (R) other cuts were at first feared to be even deeper--yet she did hire, without the legislature’s (D) authorization, 2 consulting firms to advise her how to cut Medicaid; while the Medicaid agency discovered a shortage of $100 million to pay overdue provider bills & asked the legislature to make it up.

New York---has a waiver for parents under 150% and childless, non-disabled singles & couples under 65 below 100%, but the level is only $800/mo (est.) for aged & disabled singles. ADAP’s level is 435% & CHIP’s is 400%. The legislature (D House; R Sen) set up a 313% SPAP (EPIC, which excludes the disabled) level and is now being restored mostly to its 2011 state--wrapping around Pt D, helping with copays, providing coverage during the donut hole & covering non-formulary/restricted Rx’s after ex- haustting Pt D appeals. Clients must have Pt D to get on the SPAP, which has a Pt D premium subsidy for those under 180%. The state subsidizes insurance for workers under 250%--now with only a high-deductible option ($1200 single, $2400 family), yet preventative services are covered during the deductible & a $3000/yr Rx cap was dropped. It raised Rx & MD co-pays (but caps them at $200/yr); adopted a stricter formulary that arthritis, diabetes, AIDS & mental health groups oppose (but Gov. Cuomo [D] relented on a plan to narrow the birth control formulary); and covers assisted living, chore aide & adult day care. Counties must pay ½ of the state’s 50% matching share (but their increases are capped at 3.5 %/yr). NY funded HIV day health care; covered colon & prostate cancer patients & the wkg disabled below 250%; required hospital discounts for those under 300% & banned taking debtors’ homes; and mandated mental health parity in private plans. The state has a discount Rx plan for the disabled, ended all non-long term care Medicaid, MSP & SPAP asset tests and extended COBRA to 36 mos. NYC’s public hospitals plan to cut child mental health & Rx benefits and closed some clinics. NYC proposed to end a school dental program, cut its HIV services $17 million and de-funded a health insurance advocacy office, while its Mayor proposed cutting 182 school nurse jobs. Cuomo & the legislature made $1 to $2.8 billion in Medicaid & EPIC cuts, are forcing all patients--even nursing home, HCB waiver & home care cases--into HMOs; may possibly be dropping--or tightening medical admission rules & income levels for--Katie Becket & FOA coverage of at- home disabled children; and allowing less home attendant hours. They had planned to drop coverage of child orthodontia on 10/1/12. Charts on the many, new, complex income & asset levels and disregards are in “Med. & EPIC Cuts” at http://nyhealthaccess.org, as are “Several Important Changes for..[Clients].in the..[NY State] Budget: Medicaid” & “Legislature Restores Most EPIC Cuts.” CMS & GOP Congressmen claim the state was overpaid billions for DD center care for many years---while the state is nonetheless seeking an extra $10 billion in US funds for its program-wide Medicaid revamping and to pay for its related health system reforms.

7 North Carolina---covers the wkg disabled, but allows only 8 Rx’s/mo (plus another 3 or more on an exception basis).Its aged/disabled level is 100%; its parent level is 34%/47% if wkg (‘12) & its CHIP level is 200% .Its aged-only SPAP was suspended in 2010. The legislature (R) created a 2 nd SPAP just for ADAP clients on Medicare who are under 175% but ineligible for Pt D full Extra Help & pas-sed limited mental health parity. It has a risk pool that excludes Medicare patients, requires pre-authorization & charges a $250 co-pay for “specialty” Rx’s but has low income premium discounts. The state set up a preferred Rx list proposed closing 50 mental hosp beds & cutting MD, hosp, personal aide, maternal care & community mental health funds; did cut audiology & hospice care and limited speech, occu & phys therapy visits to 3/yr. ADAP was cut $3 million; and, has a formulary limited to Tier 1 Rx’s & an income level cut from 300 to 125% The budget ends Medicaid’s HIV case manager program & coverage of community-based rehab care and many child dental X-rays & sealants; limits breast surgery; and requires prior approval of X-rays, MRIs, MRAs, PET scans, ultra- sounds & some EPSDT services. The state may even require pre-authorization for Medicaid’s HIV Rx’s. The hospitals got the legislature (R) to tax them to attract more US matching to raise their rates & meet other health costs; but, with a big budget cut, the state will limit or end coverage of adult insulin, eyeglasses, dentistry, podiatry & chiropractic care. It had to submit a corrected waiver request to get US Medicaid matching to fund board & care home care for 2,000 disabled residents; and did submit state plan amendments to better co-ordinate mental & primary care; pay coordinators extra to cut hospital re-admissions & ER visits, and bring clinics’, children’s, the disabled’s, the mentally ill’s & HIV clients’ care into fuller coordination. Gov McCrory (R) faces a big Medi- caid deficit (he may try to meet all or part of it by with funds from other accounts), but cut the state ADAP budget $8 million. The 4th Circ refused to grant a re-hearing on its order upholding a US Dist Ct order barring cuts to home personal care for the disabled

North Dakota---this 209(b) state has a risk pool with a Medicare supplement but no low income premium discount. Its aged/disabled level is $750, its parent level is 33%/57% if wkg (‘12) but ADAP’s level was cut from 400 to 300%. It covered disabled children under only 200% via the FOA, boosted CHIP’s level to 150% and raised the medically needy/spend down level for all to $750/ mo for 1 (with correspondingly higher levels for 2 or more).. The legislature (R) again raised CHIP’s level (now to 160%), but cut ADAP’s for-mulary, capped its enrollment & yearly costs and limited patient access to Fuzeon. Gov. Dalrymple (R) may make even more cuts.

Ohio--this 209(b) state has a parent level of 90% (’12), a 200% CHIP level, but cut the ADAP level from 500 to 300% —a change that a court delayed twice to allow more public input before full implementation.. Ohio cut secondary fees for dual eligibles & medical assistance for those awaiting SSA disability awards; moved most patients into HMOs (some with too few specialists); but required private insurance mental health parity. Its aged /disabled level is only $589/ mo (the US’ lowest). The state covered disabled children under 500% via the FOA; cut nursing home fees (which it later partially re-stored, while boosting home care benefits); cut Rx fees & community mental health funds; and required Rx co-pays & a generics preference rule; but restored adult dental & vision care. It told nursing homes to pay for their own patients’ phys therapy, wheelchairs & medical equipment. The state moved 592 from waiting lists into HCB waivers & imposed $718 million in fees on hospitals to be used to get more US matching & raise rates; and applied mini-COBRA rights to small firms. Gov Kasich & the legislature (both R) plan to move disabled children, the mentally ill, nursing home & HCB waiver patients, dual eligibles and, indeed, all aged & disabled into managed care; cut nursing home fees (yet still claim they’ll spend more on HCB care); hospital rates, managed care fees & psychiatric care. The ADAP program plans to enroll new clients by prioritizing them by the acuteness of their health status if funding shortages require a a waiting list. The state helped get a Me- dicaid waiver, which started 12/1/12, for Cleveland’s MetroHealth system to treat at its network facilities all Cuyahoga County adults (even the childless, non-disabled) under 138%. Kasich is streamlining eligibility for pregnant women & infants.

Oklahoma---this 209(b) state’s aged/disabled level is $752 (the est. SSI/SSP rate). The parent level is 36%/51% wkg (‘12) & ADAP’s is 200%. It doesn’t cover hospices, but did cover the breast & cervical cancer and wkg disabled groups. It subsidizes insurance for students over 18, the unemployed & small firm workers under 200%; the legislature (R) later cut its premiums & liberalized its eligibility; but also cut its benefits. The state even covers assisted living--but kept the CHIP level at only 185 %. Gov. Fallin (R) may drop pregnant women’s dentistry, durable medical equipment & nebulizers; and did cut dialysis, diabetic supply, hospital, MD & nursing home fees; raised some co-pays; seeks to limit ER visits to 3/per year; slashed the mental health budget; closed 200 mental hospital beds; cut covered brand Rx’s to only 2 per month ; and even dropped coverage of speech, occupational & physical therapy.

Oregon---this Title XVI state’s risk pool has no Medicare supplement but has low income premium discounts for those under 185%. Income levels are $710/mo for aged/disabled (the SSI rate), 30/39% wkg for parents (’12), 185% for subsidized insurance for all non- Medicare adults (with enrollment closed) & 200% for ADAP. An anti-tax referendum cut eligibility & ended adult dentistry & vision care. The OR Health Plan waiver--giving limited Medicaid to all non-Medicare adults under 201%--again closed enrollment. ADAP has cost-sharing. The legislature (then all-D) took the FOA option & passed insurer & hospital taxes--later upheld in a referendum that raised the rich’s taxes too--to cover 80,000 more children & 35,000 more adults, raise CHIP’s level to 300%, & offer more home care (but funding shortages later forced the state to end home care for hundreds of cases). Gov Kitzhaber, the Senate (both D) & the House (tied in ‘12; again D in ‘13} passed a bill to use capitated coordinated care organizations that he said will save $200 million/yr

Pennsylvania---has an aged/disabled level of 100%, a parent level of 25%/58% wkg (‘12), a CHIP level of 200% & an ADAP level of 337%. It covers the wkg disabled, raised the SPAP level to $23,500 for 1 & $31,500 for 2, but excludes the disabled. Gov Corbett & the legislature (both R) limited adult dentistry & Rx’s to 6/mo (with an exception process), required co-pays from families of disabled children over 200% (then temporarily relented, but only to require premiums for at least as much---if CMS agrees), cut mental & 8 women’s health care and abolished the Adult Basic program—with 41,000 patients on it & 496,000 more on its waiting list. But case file reviews suggest that up to 1/2 of those dropped may be Medicaid-eligible anyway, according to Community Legal Services .of Philadelphia, where city clinics must now bill even the poorest $5-$20 a visit. Corbett dropped 150, 000 more from Medicaid (including 90,000+ children). But while coverage for all the dropped children still hasn’t been fully restored, 23,000+ of them did re- apply & were reinstated and the state & Philadelphia Legal Services settled a lawsuit with the state agreeing to send mailings to 100, 000 of those dropped, inviting them to appeal their terminations within 30 days to a special state eligibility review working group.

Rhode Island---has these income levels: aged/disabled, 100%, parents, 175% (181% wkg (‘12), CHIP, 250% & ADAP, 400%. The state covers the wkg disabled & its limited formulary SPAP covers the aged but only those disabled over age 55 (with income levels of $37,167 for 1 & $42,476 for 2); it required free & discount hospital care for those under 200% & 300% and banned taking debtors’ homes. A waiver granted extra up-front US funds in exchange for shifting 12% of nursing home cases to cheaper home care & caps future US funds. The legislature (D) raised adult daycare co-pays & dropped legal alien children. Gov. Chaffee (I) may try to end the waiver (a 12/6/11 report at www.lewin.com notes its disappointing savings: only 20% of expectations, yet still capping US matching)

South Carolina---has no spend down. Its aged/disabled level is 100% & its parent level is 50%/89% wkg (‘12). It cut ADAP’s level to 300%. Its risk pool has a Medicare supplement but no low income premium discount. The legislature (R) limited Rx’s to 4/mo & raised CHIP’s level to 200%. The SPAP level is 200%, but it excludes the disabled. The state cut mental health benefits, home health, hosp & nursing home fees; closed an HIV program to new cases; passed private plan mental health parity; ended SPAP payment for Rx’s not covered by Pt D & cut its budget; de-funded cancer screening; and, for Medicaid, cut home, personal aide & HCB care (the last 3 cuts face lawsuits), cut covered Rx’s from 8 to 7/ mo and required a generics” fail first” rule for mental health, oncology & HIV Rx’s before brand Rx’s are covered. Gov. Haley (R) tried to end hospice coverage (then relented) but did cut speech & occupational therapy sessions from 225 to 75/yr. She favors ”public-private care provider partnerships”, preventing low-weight births, using HCB care over nursing homes, ending adult vision & dental care, raising co-pays and reducing C-sections & hospital re-admissions. She’s cutting hosp, MD & DDS fees $300 million. But the state is enrolling up to 65,000 more children in Medicaid in response to a mailer

South Dakota---has no spend down. Its aged/disabled level is $710/mo ( SSI’s rate), its parent level is 50% (‘12) & ADAP’s is 300% The legislature (R) wouldn’t raise the 200 % pregnant women & CHIP levels to 250% or boost provider fees, and ended adult dental coverage. Gov. Daugaard (R) cut provider fees by 10%, but the legislature restored some of that cut. The ADAP waiting list is 17.

Tennessee—The legislature (R) set the aged/disabled level at $710/mo (the SSI rate), parents’ at 67%/122% if wkg (‘12) & ADAP’s at 300%. Except for the pregnant, children & HIV+ patients, MD visits were cut to 10/yr, hosp days to 20/yr & Rx’s to 2 brand drugs + 3 generics/mo, except for some grave conditions. There’s a 250% CHIP level, a state risk pool (with no Medicare supplement but with a premium discount for those below 250%), a SPAP (with a waiting list & low benefits cap) for up to 5 generics/mo for non-Me- dicare clients under 250% & subsidized barebones insurance for those with incomes under $55,000 (enrollment is closed). CHIP uses Medicaid Rx rules, but also covers diabetic items & more psychiatric Rx’s. Home care & medical equipt benefits were cut, as were mental health care & hosp rates (by $500 million) —forcing Nashville Gen Hosp to deny subsidized non-emergency care to poor illegals. The state deferred plans to cap MD visits, transportation & transplant care, but kept a $10,000/yearly benefits ceiling; limited occu, speech & phys therapy; and capped X-ray, lab usage & ADAP costs. A court revoked its 1987 order grandfathering-in 150,000 ex-SSI recipients into Medicaid; almost all then lost eligibility (see “Daniels Case” at www.tnjustice.org). Gov Haslam (R) favors ending coverage of elective C-sections, hemophilia, detox, acne & some sedatives. The state periodically re-opens the spend down to only a limited quota of adults (see www.tnjustice.org for details); it extended & raised a hospital tax; and says it’s saving $6.25 million by diverting those who’d otherwise enter nursing homes into home care instead (but not necessarily full HCB care).

Texas—has a risk pool with a Medicare supplement & but no low income premium discount .The aged/disabled level is $710/mo (the SSI rate), the parent level is 12%/25% wkg (‘12) & the ADAP & CHIP levels are 200%. Gov. Perry & the legislature (both R) dropped CHIP prostheses, phys therapy & priv duty nursing; raised CHIP cost-sharing; cut Medicaid home health & ended adult chiropractic & podiatry care; but restored Medicaid vision & hearing aid coverage and CHIP dentistry (Medicaid covers limited adult dentistry) and required some mental health parity in private plans. Texas has a SPAP for HIV clients. The legislature cut the Children with Special Health Needs program & a cystic fibrosis program for all ages (even with 950 kids on a waiting list); wouldn’t fund 13,000 needed HCB slots; or $19 million that ADAP requires; and even authorized cutting its income level from 200 to 125% if necessary. It left $4.8 billion of Medicaid’s budget unfunded after mid-2013, when it must either get more money or make big Medicaid cuts—and even authorized a transfer of $19 million from Medicaid’s skimpy budget to ADAP’s even worse budget. A CMS waiver puts more patients in managed care; but will drop the state’s 3 Rx’s/mo limit for such enrollees (making up costs with Rx dispensing fee cuts) and cover more child dentistry. CMS won’t fund TX’s family planning/ women’s health programs since they exclude Planned Parent- hood. So Perry will try to fund them with state funds only---and will still bar Planned Parenthood. He stopped paying the full Medic- are rate for dual eligible co-pays—and now pays only Medicaid’s lower rate (but relented on psychiatrist, psychologist & oncologist bills). Due to billing disputes, many orthodontists left Medicaid & CHIP—abandoning 50,000-250,000 child patients (most of whom need continued brace management/ & monitoring, with many due or even overdue for brace removal); but Pro Ortho, an ad hoc af- filiate of the TX orthodontist society, organized 20 pro bono volunteer orthodontists to give these patients emergency treatment.

9 Utah—is a Title XVI state with a risk pool that has a low income premium discount, but no Medicare supplement. Its aged & parent income levels are 100% & CHIP’s is 200%. A waiver (closed to new clients), gives limited O/P—but no I/P--care, with big co-pays, to all childless, non-Medicare adults under 150%. The state cut coverage of some wheelchairs, chiropractic, adult eyeglasses &, dentistry; cut hospital & DDS fees 25%; but subsidizes insurance for small firm workers under 150%. Gov. Herbert (R) restored child & pregnant women’s dentistry & some physical & occu therapy, but cut ADAP’s formulary & income level to 250% and capped enrollment at the present 450 clients. He cut the disabled income level (from 100 to 74%), slashed school health funds & the pregnant women’s asset level; and ended the spend down. He signed a bill to make waiver clients do community work, and seeks to cut eligibility and run Medicaid with a 2nd managed care waiver in the 4 biggest counties (which some say uses sub-par ACOs, with high Rx & child co-pays and $40/mo premiums. but CMS then barred its “excessive” cost-sharing). The legislature required pre-authorization for 1 type of mental health drug & is considering higher smoker cost-sharing. The state offers autism care, but with a cap of only 200 clients

Vermont—Its levels are: aged/disabled (2 zones) 101% & 110%; parents, 185% wkg or not (’12); CHIP, 300%; ADAP, 200% & the SPAP, 175%. There are no MSP asset tests. Others (including the childless, non-disabled) under 300% get state-subsidized insurance. Dentures aren’t covered & there’s a $495/yr adult dental care cost cap. A waiver, in return for more US funds, moves patients into HMOs and favors home & HCB care over nursing homes--but in exchange caps future matching funds. Ex-Gov Douglas (R) signed a bill requiring more private plan autism coverage. The state plans authorization “edits” for atypical anti-psychotics, Chant- ix & nicotine replacement products; to require $3 co-pays for both Medicaid & SPAP Rx’s; to establish a formulary; and to “change” Rx dispensing fees. Gov Shumlin & the legislature (both D) passed a law to establish a state universal coverage health insurance plan

Virginia---this 209(b) state’s parent level is 25/30 % wkg (‘12), the aged’s & disabled’s is 80%, CHIP’s is 200% & ADAP’s is 400%. It covers the wkg disabled. Gov McDonnell & the House (both R; the Sen. is tied) cut provider fees and mental health, substance abuse & community care funds. The HCB waiver had a waiting list of 6,000 but then $30 million more was found for it. Virtually all (except Hep C) HIV-related Rx’s are again covered in ADAP’s formulary, which was even further expanded. Llikewise, ADAP is again open to enrollment by all, with an income level of 400%. A SPAP covers TrOOP & donut hole expenses & cost-sharing for HIV+ Pt D clients under 400%. ADAP is paying 350-450 clients’ premiums, deductibles & co-pays in the US-funded risk pool (which is now closed to new enrollees), cutting per capita costs from $12,000 to $8,000/yr, McDonell implemented a law to make big firms’ health plans cover some autism care so narrowly as to make it ineffective. The state & the US settled a suit that’ll require VA to open 4,000 more slots in community mentally disabled facilities (even though it says it can’t afford to). VA offers Medicaid & CHIP to poor-enough pregnant, in-labor & post-partum alien women & children even if they’ve been legally present in the US less than 5 yrs.

Washington--its risk pool has a supplement open to some, but not all, on Medicare. Its aged/disabled level is $756 (the est. SSI/SSP rate), its parent level is 35%/71% wkg (‘12) & ADAP’s remains 300%. Ex-Gov Gregoire & the legislature (both D) passed mental health parity. Funding shortages forced her to end CHIP (with a 300% level) for 27,000 illegal aliens. The state raised Basic Health (subsidized insurance for those under 200%, with a waiting list of 150,000) premiums & co-pays, forcing 60,000 off the rolls; and limited “unnecessary” ER visits (but then partially relented), Rx, DME, imaging, denture, diabetic items, personal aide, home care, adult daycare, maternity, infant casework & incontinence benefits and cut Rx, pediatric MD & HMO fees. It dropped adult hearing aids, podiatry, eyeglasses, dentistry, & colorectal cancer screening. Three non-HIV Rx’s were cut from ADAP’s formulary and cost-sharing was required of those with incomes over 100% or not on Medicare or Medicaid. CMS now pays matching for BasicHealth & “Disabil- ity Lifeline” medical assistance, but first the state cut 17,000 more off BasicHealth. The legislature cut Medicaid’s provider budget $4 billion over hospital & home care worker opposition. Gregoire signed a nursing home tax to be used to get more matching to raise their rates & other costs and sought a waiver to use “ individual per cap payments.” Gov Inslee (D) faces much the same budget issues

West Virginia---has an aged/disabled level of $710/mo (the SSI rate), a parent level of 16%/31% if wkg (‘12) & a 325% ADAP level. It covers only 4 brand name Rx’s/mo (plus 6 generics). Its state risk pool has no Medicare supplement but low income premium discounts were once authorized. It denies all adult dental care but extraction & pain emergencies & didn’t properly adopt nursing home & HCB medical admission rules (which still impede access). The state has an Rx aid plan (through low income clinics) for non-Medi- care adults under 200%. CMS halted, over state objections, to a waiver that, to cut ER costs, offered clients more mental health care & Rx’s--but only if they signed “personal responsibility” pledges; yet a study, “Medicaid Reform & ER Visits..” (12/18/12), at www.mercatus.org finds that the waiver actually raised ER costs. Gov Tomblin & the legislature (both D) raised CHIP’s level to 300% & passed a hosp assessment tax with proceeds to be used to get more Medicaid matching, but had to close admission to HCB slots.

Wisconsin---has an aged/disabled level of $793.78/mo (the est. SSI/SSP rate), and 300% ADAP & a 240% SPAP (which excludes the disabled) levels The risk pool has a Medicare supplement & premium discounts for those under $33,000. The state raised the CHIP (to 300%) & parent (to 200%) levels and offered a limited Basic Care plan to childless non-Medicare adults under 200% (but new enroll- ments were later barred). Gov Walker & the legislature (both R) cut the income levels to 133% for parents & for the 67,000 childless adults on Basic Care (with many, many more on its waiting list). He raised premiums, imposed more & higher co-pays and “adjusted” dialysis & Rx dispensing fees. Yet even GOP legislators spurned his plan to cut SPAP coverage

Wyoming--has no spend down, an aged/disabled level of $735 (the est. SSI/SSP rate), a parent level of 37%/50% wkg (‘12) & a 200% CHIP level. Its SPAP, with a 100% level, covers anyone not on Medicare. The legislature (R) widened CHIP dental, vision & 10 mental health benefits and added a state risk pool low income premium discount with a 250% level (it already had a Medicare supplement). Gov Mead (R) planned to cut provider fees, DD & HCB costs (freezing-in a waiting list) & dialysis aid. ADAP’s 332% level & formulary were cut and enrollment was capped at 135, with more cost-sharing. The state tested (inconclusively) an HSA pilot plan.

SOURCES AND RESOURCES:

Email [email protected] for “State Asst. Progs. For SSI Recips., 1/11” (the latest update) on state Medicaid eligibility rules for SSI & SSP recipients, their independent-living and board & care home SSP figures & Section 1616, 1634 & 209(b) arrangements

For the 48 states & DC,2013’s federal poverty level (FPL) is $11,490 yearly ($957.50 monthly) for one person plus $4,020 yearly ($335 monthly) for each additional person. 201 2 ’s FPL was $11,170 yearly ($930.83 monthly) for one plus $3960 yearly ($330 monthly) for each additional person; see the Assistant Secretary for Planning & Evaluation pages at www.dhhs.gov for earlier years’ FPLs and AK’s & HI’s separate FPLs. The 2013 SSI rates (not including any added state supplementary payments, or SSPs) are $710 for one person & $1066 for a couple.

For the latest state parent & childless, non-disabled adult income levels (as percentages of the current or 2012’s FPL) see Table 4 at pp. 33-35 in “Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, & Cost-Sharing Policies in Medicaid & CHIP, 2012-2013.”(1/23/13) at www.kff.org Also see http://www.kff.org/medicaid/upload/8105.pdf for more detailed 2010-11 aged, disabled & MSP eligibility data (especially Appendix A4a) & “State General Assist. Programs. 2011” at www.cbpp.org for data on state General Assistance welfare income levels--- and, in many states, even income & other eligibility rules for their General (non-federally-matched) M edical Assistance.

See “Explaining: Benefits & Cost-Sharing..States Can Set For [New]..[ Eligibles] ..” (8/9/10) at www.kff.org . For CMS rules on covering newly-eligible clients & their benefits see State Med Dir Ltr #10-005 and “New Options.. [In] Med..” (4//10/10).

Problems with enrollment & access to providers for recipients of the QMB program--and how to overcome them--is discussed in a 12/15/11 “CMA Alert” at www.medicareadvocacy.org, an 11/11 /11 “Issue Brief” at www.nsclc.org and “The Medicare Savings Programs [MSPs, Including QMB]: …Increasing Enrollment”, GAO Report 12-871 of 08/13/12 at www.GAO.gov .

See “Expanding MediCal;, Profiles of Potential New Users”(8/11/12) questioning if previously-uncovered patients added by health reform expansions will cost any more than parents do now; Google “Health Service Among the Previously Uninsured”, in Health Economics (8/24/11), for similar findings for those uninsured 1st getting Medicare. See “Health Care Costs Decreased [by nearly half] For Newly Enrolled When [Poor] Uninsureds [with 128,000 study subjects under 200%, from 2001 to 2007 ]…[Got] …Coverage” at www.today.uci.news ( 2/15/12 ).

See ”Updated Analyses .. National and State-Level Data.. [and Figures].. on Coverage and Costs…of Expanding Medicaid Under the ACA” at www.kff.org (pub. # 8384, 11/26/12). “Net Effects of the [PPACA] on State Budgets” at www.firstfocus.net sees state savings of $40.6 to $131.7 billion/yr in 2014-19 and “Considerations in Assessing State-Specific Fiscal Effects of the ACA’s Medicaid Expansion” (8/12) at www.ui.urban.org.

The ACA offers a 90% US match to set up & improve eligibility & enrollment systems, plus a permanent 75% US match to run them (the old Medicaid match for state eligibility, staff, management & claims-payment was only 50%). And until 2/12/15 the 90% start-up funds are available for some TANF & SNAP administrative & eligibility costs. See http://www.fns.usda.gov/snap/rules/Memo/2011/081011.pdf . & the Seven Conditions and Standards .

See “PPACA’s State Savings & Costs..” in “pubs at www.ui.urban.org, projecting state savings of $92-$129 billion in 2014-19 & $12-$19 billion/yr later; “How Health Reform’s Med. Expansion ..Impact[s] State Budgets”, “Guid-ance..in Analyzing & Estimating Cost[s] of Expanding Med.” at www.cbpp.org ,& Rpt 12-921 at www.GAO.gov Three good resources on NHeLP’s website (www.healthlaw.org) can help advocates implement the ACA’s adult Medicaid expansion in their states: NHeLP’s Guide for Evaluating Fiscal Analyses of the ACA’s Adult Medicaid Expansion ; Top Five Myths and Facts about the Cost of the ACA’s Adult Medicaid Expansion,; and Coverage for Lower-Income Adults: Exchange versus Medicaid . See www.familiesusa.org for “A Closer Look: Simplify..Enrollment & Elig..” on MAGI income-counting rules for the non-aged/disabled, and http://www.healthlaw.org/images/stories/2013_04_Vol_12_Health_Advocate.pdf . A toolkit on Med. expansion is at http://www.healthlaw.org/index.php?option=com_content&view=article&id=701:state-advocacy-resources&catid=51:healthreform&Itemid=176 . http://medicaidbenefits.kff.org/index.jsp lists optional services states cover (e.g., chiropractic, podiatry, eyeglasses, optometry, hearing aids, hospices, psychologists, prosthetics, home health, medical equip, dentistry, Rx’s, OTC & first aid items and phys, occu & speech therapy, etc.) and has data on their scope, reimbursement, limitations & prior authorization rules as of 2010. See 11 “Responding to [State] Medicaid Service Cutbacks: An Advocates’ Checklist” in the Jan/Feb. 2012 issue of Clearinghouse Review ($15 fee; email [email protected])

The “2013 National ADAP Monitoring Report (Module 1)” at www.nastad.org has state financial eligibility rules and application procedures in its text, plus various charts & tables. Its Module 2 ---due out in 3/13, and to be merged then with Module 1—has enrollment & utilization data, details on ADAP coordination with Pt D, the US’ health reform-funded Pre- existing Condition Insurance Plans (PCIPs) risk pools & Sec. 1115 waivers & coverage of hepatitis treatments & drugs. www.nastad.org has the recently-issued common application form for all HIV Rx makers’ Patient Assistance Programs (PAPs), updated “ADAP Cost Containment Technical Assist. Briefs” & a very handy “Co-ordination of Benefits” paper.

“ Medicaid & HIV: A National Analysis” (doc. #8218 at www.kff.org) studies enrollment & spending for HIV patients. CMS--while pressed for a widening by Congressmen & advocates--reconsidered, but stilly retained, a 1-Rx-per-class floor for the ACA Essential Health Benefit (but requires at least as many covered Rx’s as state benchmark plans do).

See “Pharm. Benefits [in…Medicaid Progs.]” at www.npcnow.org on formularies, fees, prior auth., prescrib/dispensing limits & co-pays. States can cover Pt D-excluded Rx’s with their own funds: see which do at www.medicareadvocacy.org (12/1/05 report at “News” icon). “Implementation of Med. Pt D & Its Non-Rx [Costs]..”in jama.ama-assn.org (7/27/11) says Pt D Rx’s cut other patient health costs $1,200 yr.

A 2012 Med./CHIP Payment & Access Com. (MACPAC) rpt, http://www.modernhealthcare.com/Assets/pdf/CH78650315.PDF focuses on disabled Med. patients, reports on a survey of quality measures ( more than HHS’ core standards) that managed care plans use, including some HIV measures (at page 7) and lists Medicaid optional benefits (e.g., HIV tests & targeted case mngmnt). “Medicaid Managed Care Trends” (’09; ‘10) can be found, with some effort, on Medicaid’s research & demonstration pages at www.cms.gov; it reports that over 70% of Medicaid patients are already enrolled—often mandatorily--in private managed care plan, often run by private contract insurance firms (so far these are mostly non-disabled parents & children); but most states are now enrolling (often mandatorily) the formerly mostly-exempt aged & disabled. The Association for Community Affiliated Plans’ (ACAP) Medicaid-Focused Health Plans Continue Outsized Growth as Medicaid Trends Toward Managed Care, charts the growth of Medicaid managed care. CMS has a new Technical Assistance Center for States on Medicaid Managed Care (here). It adds new managed care technical resources -- like a map showing managed care penetration -- to its website (here). This collaboration between CMS & partner organizations aims to help states plan & procure better oversight, benefit design, access to care, quality measurement, etc. States can request individual technical support on setting up managed care systems (here).

CMS has issued FAQs on state options for premium assistance to buy health insurance, especially for expansion eligibles They are at http://medicaid.gov/State-Resource-Center/Frequently-Asked-Questions/CMCS-Ask-Questions.html. For the NHeLP’s take on this see http://www.healthlaw.org/images/stories/Premium_Assistance_FAQ_Summary.pdf There’s also a policy/legal brief at http://www.statenetwork.org/wp-content/uploads/2013/03/State-Network-Manatt-Purchasing-Coverage-for-Medicaid- Beneficiaries-in-the-Exchange.pdf. For a contrary advocates’ view, see “Privatization: Not Right for Medicaid…” (4/13) at http://www.medicareadvocacy.org/articles/ and, to read about a successful current working state alternative to managed care, see http://www.citizen-times.com/article/20130430/OPINION07/304300001/Great-Medicaid-model-already-exists-NC?nclick_check=1.

Gov. Beebe (D-Arkansas) favored Medicaid expansion, & offered a compromise of giving the new expansion eligibles purchased private insurance instead of outright “Medicaid “ itself---which the GOP legislature approved---a distinction without much real difference, since states already buy private coverage for over 70% of their Medicaid patients. But this purely nominal genuflection to what conservatives (including Arkansas state legislators) see as the ideological wonders of the private “free market” is neverthe- less irresistibly tempting to many---but not all---of them. See a critical, and very distorted, screed by right wing health policy ideol- ogue Avik Roy in Forbes magazine, dismissing the plan as just a warmed-over version of the Medicaid program that they so hate. Yet this clever solution (a cost-free bone of empty labeling tossed to, and swallowed by,-at least some conservatives) seems to be gladly accepted-- tentatively, in principle and with some benefit package & affordability provisos-- as a useful policy coup for HHS

Email [email protected] for the latest amounts of state Personal Needs Allowances (PNAs) for those in SNFs, ICFs and licensed board & care homes. See a “Medicaid HCB..Data Update: 2012” at www.kff.org , AARP’s www.longtermscorecard.org on state LTC programs & http://www.cdc.gov/nchs/data/databriefs/db78.htm for a survey on board & care homes. An AARP, NASUAD & HMA study reports on a survey of state agencies at http://www.aarp.org/health/health-care-reform/info-02- 2012/On-the-Verge-The-Transformation-of-Long-Term-Services-and-Supports-AARP-ppi-ltc.html & in 12 related papers showing which states are pursuing Managed LTSS & HCBS options offered by the ACA. See AARP Public Policy Institute’s “Medicaid: A Program of Last Resort for People Who Need Long-Term..[Care]..” at full report and printable infographic.

See www.naschip.org on pre-2010 state risk pools & order “Comp. Health Ins. for High Risk Individuals:.. State-by-State…” on their funding, eligibility, benefits, Medicare supplements, premiums & low income discounts. www.pcip.gov shows if the now- closed US ACA-funded pools were state- or US-run; the latter’s premiums/cost-sharing were quite affordable for those under 40.

See the “Directory of..[the 27]..State Kidney Programs” with eligibility & benefit data under “publications” at http://som.missouri.edu/MOKP/.

See “Friday Updates”, “State Medicaid Reform Tracker (6th ed.)”, “State Aging & Disability Agencies in Time of Change” and reports on long term care managed care & service initiatives for dual eligibles at www.NASUAD.org. See “St@teside” at www.sci.academyhealth.org on expansion, new clients’ costs, essential benefits & “Reasonable…Models for Income Verification” http://healthlaw.org/images/stories/medicaiddefense/2011_08_02_NheLP%20Cost%20Sharing%20Summary.pdf cites studies showing that adopting or raising low income patients’ cost sharing always, inevitably delays or deters their access to care Also see related papers at http://ccf.georgetown.edu/index/cms-filesystem-action?file=ccf%20publications/state-specific/florida- 2011/medicaid-brief-2012-changes-dec-11.pdf and http://annfammed.org/content/11/1/37.full. Check “Dispelling Myths About [ER Use]; ..[Most}..Medicaid Visits [Really] Are For Urgent or Serious Symptoms”(7/12) at www.chsc.org .

See “Medicaid Eligibility, Enrollment, Simplification & Coordination Under the ACA: A Summary of CMS’ 3/25/12 Final Rule” (doc # 8391, 12/11/12), “Medicaid Eligibility & Enrollment for People with Disabilities Under the ACA: The Impact of CMS’ 3/23/12 Final Regulations “ (doc #8390, 12/11/12) at www.kff.org , and “Eligibility & Enrollment Systems: An Advocate’s IT Toolkit” (11/12/12; with a glossary) under the “Affordable Care Act” icon at www.ccf.healthpolicyinstitute.georgetown.edu .

A little-known 1997 CMS policy issuance to its regional offices (better readable in a 1998 Region IV re-issuance to states) at http://www.ncauditor.net/EPSWeb/Reports/Performance/PER-2010-7260.pdf) allows Medicaid matching for otherwise-eligible penal inmate I/P care at non-penal hospitals, SNFs & ICFs. But Medicaid’s ban on matching for inmate care inside penal facilities & infirmaries--and for non-overnight O/P care at non-penal clinics, ERs & MD offices—still applies. In 2014 almost all inmates will qualify (since almost all are in-digent) for I/P care in non-penal hospitals, SNFs & ICFs. Contact [email protected] (517-282-2124) for details.

See “Coverage For Inmates of Public Institutions…”& “Juvenile Justice & Medicaid” at www:healthlaw.org. Read www.nationalreentryresourcecenter.org/documents/0000/1181/Reentry_Council_Mythbuster_Medicaid_Suspension.pdf and www.nationalreentryresourcecenter.org/documents/0000/1205/Reentry_Council_Mythbuster_Juvenile_Medicaid.pdf on how states can “suspend”— not terminate—eligible incarcerated persons’ coverage for immediate access to full Medicaid on release and also for I/P care at non-penal facilities even while still incarcerated.

See “Designing the Essential Health Benefit [Under the ACA] in Your State: An Advocate’s Guide” at www.familiesusa.org . Citations at http://povertylaw.org/communication/webinars/medicaid-eligibility offer arguments, data & ways to urge state staff to take the ACA option to give Medicaid to all adults (both parents & the childless non-disabled) below 138%. The National Conference of State Legislatures tracks state health reforms, with contacts, reports, research, fiscal analyses, presentations, etc. at http://www.ncsl.org/issues-research/health/state-implementation-entities-to-implement-the-aca.aspx.. as does http://healthreform.kff.org/federal-funds-tracker.aspx . For state Medicaid expansion, see ”States .. Getting a Jump Start on Health Reform’s Medicaid Expansion” at http://www.kff.org/medicaid/quicktake_medicaid_expansion.cfm.

For CMS’ mandated “Summary of Benefits & Coverage” (SBC) universal form template & its “Glossary” for insurance plans , see http://cciio.cms.gov/resources/files/sbc-template.pdf & http://cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary- final.pdf respectively.

Data on what Medicaid and CHIP “per capita caps” are (which GOP Congressmen & Governors are toying with & may mandate-- and how they threaten state budgets and patients’ care--- are at http://www.cbpp.org/cms/index.cfm?fa=view&id=3846., http://www.healthlaw.org/images/stories/NHeLP_Understanding_Medicaid_Block_Grants_and_Per_Capita_Caps.pdf , in “Medicaid [and CHIP] Caps Jeopardize ..Health..]”..at www.firstfocus.org and at http://www.cbpp.org/files/5-8-13health.pdf . 13 “Coverage of Preventive Services for Adults [in Medicaid]” at www.kff.org (doc. # 8359) says states already cover almost all recommended preventive services for adults. Prevention & screening costs will be matched 1% higher under the ACA Read about doubts of their efficacy & cost-savings value in “Gen. Health Checks…For [Cutting..Illness & Death]..” at www.cochranecollaboration.org (at “library”; possible fee) and in ”Gen. Health Checks in Adults for [Cutting] Morbidity & Mortality” (1/14/13 ) under “Internal Medicine” at www.JAMANetwork.org

CMS issued final rules (77 Federal Register 66669, 11/6/12) to pay all states additional costs for raising their reimbursement for physician services in family medicine, internal medicine & pediatrics to roughly equal Medicare rates, starting 1/1/13 though 12/31/14---but only MD, MA, MI & NV have so far done so; see http://www.dailyherald.com/article/20130526/business/705269993/

HHS ruled that states can’t claim the higher matching rate for raising their income levels for adults (including the childless, non- disabled) to less than 138%. See Question # 26 at http://cciio.cms.gov/resources/files/exchanges-faqs-12-10-2012.pdf

At www.kff.org, see The Single Streamlined Application Under the Affordable Care Act: Key Elements of the Proposed Application and Current Medicaid and CHIP Applications , which has a model form released for comment by CMS. The ACA requires states to adopt this streamlined form, or develop their own subject HHS approval, ready for the launch of the Exchanges in October 2013.

A new AARP Public Policy Institute summary of state studies showing the cost-effectiveness of home & community-based services is at http://www.aarp.org/health/medicare-insurance/info-03-2013/state-studies-find-hcbs-to-be-cost-effective-AARP-ppi-ltc.html

FamiliesUSA had the Lewin Group calculate the numbers of those eligible for subsidized health insurance premiums (with incomes between 100% & 400%) under the Affordable Care Act, nationally and state-by-state, at http://www.familiesusa.org/help-is-at-hand/ The Center on Budget and Policy Priorities (CBPP) has a helpful FAQ on Premium Tax Credits – the new federal tax credits created by the ACA to help purchasers of health insurance after 1/1/14. In addition, CBPP is hosting a related webinar on Premium Tax Cre- dits on Wednesday, June 5, at 1 pm EST. It will go beyond the basics of who will qualify for the credits to examine some of the ma- jor technical issues about how the credits work, including how the premium tax credits are calculated, factors that affect how much consumers who are eligible for premium tax credits will ultimately pay for coverage, the impact that midyear changes in income or household size have on eligibility for and amount of premium tax credits, and how the reconciliation between the premium tax credit amount a person receives and the amount for which he or she was eligible will be handled. For more information on, and to register for, the webinar click here.

See http://medicaidpharmacysavings.com/ for a summary of reforms which the Pharmaceutical Care Management Association estimates can save state Medicaid programs over $74 billion annually..