YEAR-END REPORT - 2019 Published 23-Dec-2019 HPTS Issue Brief 12-23-19.33 Health Policy Tracking Service - Issue Briefs Medicaid Medicaid Waivers Authored by Logan C. Mortenson, a Compliance Attorney at Thomson Reuters and a member of the Minnesota Bar. 12/23/2019 I. INTRODUCTION Most waivers in 2019 continued to pertain to activity surrounding Medicaid expansion and the implementation of work requirements as an eligibility criterion. Due to the Trump administration's willingness to approve waiver requests by states to seeking to impose work requirements, there has been continued legislative activity on the subject. II. STATE ACTIONS IN 2016 Disabled and Mental Health Services Selected Legislation West Virginia On January 11, 2019, 2019 WV H.B. 2336 (NS) was introduced. If adopted, it will add WV ST § 9-5-27 regarding I/DD Medicaid HCBS Waiver Requirements. Selected Regulations Alabama Effective October 10, 2019, 2019 AL REG TEXT 526141 (NS) amends AL ADC 580-5-30-.14 (Freedom of Choice; DMH Medicaid Waiver Programs). Alaska Effective November 10, 2019, 2019 AK REG TEXT 527171 (NS) adopted changes to emergency regulations regarding Behavioral Health 1115 Waiver Services. California On December 14, 2018, 2018 CA REG TEXT 512126 (NS) provided notice of amendments to the 1915(c) Home and Community - Based Services (HCBS) Waiver for Persons with Developmental Disabilities. On August 2, 2019, 2019 CA REG TEXT 530272 (NS) provided notice that the Department of Health Care Services (DHCS) in partnership with the Department of Developmental Services (DDS) is seeking to amend the 1915(c) Home and Community-Based Services (HCBS) Waiver for Persons with Developmental Disabilities. Delaware On February 1, 2019, 2019 DE REG TEXT 516233 (NS) provided notice of a proposed renewal for the DDDS Lifespan HCBS Waiver. District of Columbia © 2020 Thomson Reuters. No claim to original U.S. Government Works. -1- Effective February 7, 2019, 2019 DC REG TEXT 517046 (NS) provided notice of the adoption, on an emergency basis, of amendments to Chapter 9 (Medicaid Program); and Chapter 42 (Home and Community-Based Services Waiver for Persons who are Elderly and Individuals with Physical Disabilities) of Title 29 (Public Welfare) of the District of Columbia Municipal Regulations (DCMR). Idaho Effective January 1, 2019, 2018 ID REG TEXT 494444 (NS) amends ID ADC 16.03.10.326 (Aged and Disabled Waiver Services: Coverage and Limitations) reauthorizing the Idaho Home Choice Program to continue after September 30, 2020 by modifying 1915(c) Home and Community Based Services (HCBS) Waivers. Mississippi Effective June 1, 2019, 2019 MS REG TEXT 522154 (NS) was adopted. It removes the Assisted Living Waiver, Elderly and Disabled Waiver, Independent Living Waiver, and Traumatic Brain Injury/Spinal Cord Injury Waiver's requirements to complete the PASRR. New Hampshire On May 30, 2019, 2019 NH REG TEXT 524822 (NS) provided notice of a proposal to readopt He-E 801 with amendments, describing eligibility for, services covered by, and provider requirements for the Choices for Independence (CFI) program, which is a Medicaid 1915(c) waiver program for seniors and adults with disabilities, also known as the Home and Community Based Care program (HCBS- CFI) or CFI waiver program. Ohio Effective January 1, 2019, 2018 OH REG TEXT 506723 (NS) and 2018 OH REG TEXT 506724 (NS) rescind, amend and adopt various Developmental Disability Home and Community-Based Waiver Service provisions. Texas Effective July 23, 2019, 2019 TX REG TEXT 519332 (NS) and 2019 TX REG TEXT 519333 (NS) repeal and establish new sections regarding the HCBS Adult Mental Health program. Virginia On February 4, 2019, 2019 VA REG TEXT 436613 (NS) proposed to redesign three existing home and community based waivers as follows: Individual and Family Developmental Disabilities Support Waiver (12VAC30-120-700 et seq.) is changing to the Family and Individual Supports (FIS) Waiver, Intellectual Disability Waiver (12VAC30-120-1000 et seq.) is changing to the Community Living (CL) Waiver, and the Day Support Waiver for Individuals with Mental Retardation (12VAC30-120-1500 et seq.) is changing to the Building Independence (BI) Waiver. Wyoming Effective September 23, 2019, 2019 WY REG TEXT 524476 (NS) adopts children's mental health waiver rules. On September 26, 2019, 2019 WY REG TEXT 535337 (NS) provided a notice of intent to adopt rules regarding Environmental Modifications and Specialized Equipment for Medicaid Home and Community-Based Waiver Services; DD Waiver Provider Standards, Certification, and Sanctions; Medicaid Supports and Comprehensive Waivers. Home- and Community-Based Services Selected Legislation California On October 12, 2019, 2019 CA S.B. 289 (NS) was adopted. It adds Section 14132.993 regarding home and community-based waiver services for military service members. Iowa On February 6, 2019, 2019 IA H.F. 296 (NS) was introduced. If adopted, it will modify the enrollment process for Medicaid home and community-based services (HCBS) waivers. Maryland © 2020 Thomson Reuters. No claim to original U.S. Government Works. -2- On February 4 and 8, 2019, 2019 MD H.B. 1009 (NS) and 2019 MD S.B. 700 (NS) were introduced. If adopted, they will repeal the initial cap on participation in an HCBS waiver and require an HCBS waiver submitted by the Maryland Department of Health to the Centers for Medicare and Medicaid Services to include a request for a cap on waiver participation that is set at no less than a certain percentage of the projected annual demand for certain services. On May 13, 2019, 2019 MD S.B. 699 (NS) was adopted. It prohibits the Maryland Department of Health from denying an individual access to a home- and community-based services waiver due to a lack of funding for waiver services if the individual is living at home or in the community at a certain time, received certain services, will be or has been terminated from the Maryland Medical Assistance Program due to certain entitlement or enrollment, meets certain eligibility criteria, and certain services received by the individual would qualify for certain funds. Minnesota On May 22, 2019, 2019 MN S.F. 573 (NS) was adopted. It revises various sections regarding home and community-based services for elderly individuals. Mississippi On January 21, 2019, 2019 MS S.B. 2739 (NS) was introduced. If adopted, it will authorize the Division of Medicaid to apply for federal waivers to authorize transitioning active duty military service members to use their state of legal residence to qualify their dependents [FN1] with special needs for HCBS reimbursement. Missouri On February 25, 2019, 2019 MO S.B. 441 (NS) was introduced. If adopted, it will modify provisions relating to certain MO HealthNet home and community-based services. Montana On April 18, 2019, 2019 MT H.B. 529 (NS) was adopted. It revises requirements regarding waiting list criteria for home and community- based services. Nevada On June 7, 2019, 2019 NV S.B. 425 (NS) was adopted. It requires the Director of the Department of Health and Human Services to amend the State Plan for Medicaid to provide certain additional home and community-based services. New Jersey On March 18 and 25, 2019, 2018 NJ S.B. 3593 (NS) and 2018 NJ A.B. 5219 (NS) were introduced. If adopted, they will require the Division of Medical Assistance and Health Services in DHS to accept permanent change of station order for purposes of satisfying residency requirement for provision of home and community-based services under certain circumstances. New York On April 3, 2019, 2019 NY S.B. 4972 (NS) was introduced. If adopted, it will establish payment criteria for home and community based long term care services. Ohio On November 6, 2019, 2019 OH H.B. 287 (NS) was engrossed. If adopted, it will enact a section regarding Medicaid home and community-based waiver services for relatives of active duty military. Rhode Island [FN2] On February 13 and 27, 2019, 2019 RI S.B. 280 (NS) and 2019 RI H.B. 5566 (NS) were introduced. If adopted, they will expand the number of persons eligible for home and community care services to the elderly to include those persons under the age of 65 suffering from Alzheimer's disease or a related dementia confirmed by a licensed physician with income not exceeding 250% of the federal poverty level. Texas © 2020 Thomson Reuters. No claim to original U.S. Government Works. -3- On March 7, 2019, 2019 TX S.B. 1957 (NS) was introduced. If adopted, it will require HCBS participants to receive a personal needs allowance no less than $85 of the participant's monthly SSI. Selected Regulations Alabama Effective December 24, 2018, 2018 AL REG TEXT 505601 (NS) amends AL ADC 560-X-52-.03 (Eligibility) regarding the Home and Community-Based Living at Home (LH) Waiver. Effective December 24, 2018, 2018 AL REG TEXT 505598 (NS) amends AL ADC 560-X-52-.01 (Authority and Purpose) regarding the Home and Community-Based Living at Home (LH) Waiver. Alaska Effective June 13, 2019, 2019 AK REG TEXT 505501 (NS) adopts regulation changes dealing with Medicaid home and community- based waiver services, nursing oversight and care management services, and adopted-by-reference materials. Arkansas Effective January 1, 2019, 2019 AR REG TEXT 506903 (NS) revises Medical Services policy to provide clarification that the penalty period start date for a Home and Community-Based Waiver Services (HCBS) applicant is no later than the point at which the applicant would otherwise be receiving HCBS waiver coverage except for the penalty. It also clarifies that an individual can establish their own special needs trust. Effective January 1, 2019, 2019 AR REG TEXT 506904 (NS) is updating and changing the rules governing the ARChoices in Homecare s. 1915(c) Home and Community-Based Services (HCBS) Waiver Program (ARChoices), IndependentChoices, Living Choices Assisted Living, Program of All-Inclusive Care for the Elderly (PACE), and Personal Care Provider Manuals. California On February 1, 2019, 2019 CA REG TEXT 516045 (NS) provided notice of renewal of the 1915(c) HCBS Multipurpose Senior Services Program (MSSP) waiver. On October 25, 2019, 2019 CA REG TEXT 538038 (NS) provided notice that the Department of Health Care Services in partnership with the Department of Developmental Services is seeking to amend the 1915(c) Home and Community Based Services Waiver for Persons with Developmental Disabilities. Colorado On March 10, 2019, 2019 CO REG TEXT 519155 (NS) provided notice that the Department intends to submit waiver amendments for specified Home- and Community Based-Services (HCBS) waivers. Effective September 13, 2019, 2019 CO REG TEXT 536754 (NS) amends, via emergency rule, to update the rules to be in alignment with statute and define the changes made to the HCBS-CHRP waiver. Delaware On April 1, 2019, 2019 DE REG TEXT 520608 (NS) provided notice related to the renewal of Pathways to Employment Home and Community Based State Plan Amendment authorized under 1915 (i) of the Social Security Act. Florida On June 5, 2019, 2019 FL REG TEXT 525351 (NS) provided notice of development of proposed rules and negotiated rulemaking. If adopted, it would provide training requirements for Home and Community Based Services Medicaid Waiver Providers. Indiana On November 20, 2019, 2019 IN REG TEXT 539956 (NS) provided notice of intent to adopt amendments regarding the addition of criteria for post-eligibility treatment of incomes for members receiving home and community-based service waivers. Louisiana Effective December 20, 2018, 2018 LA REG TEXT 504129 (NS) amends various sections regarding Home and Community-Based Service Waivers—Adult Day Health Care Waiver. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -4- Effective January 20, 2019, 2019 LA REG TEXT 507157 (NS) amends LAC 50:XXI Chapter 137, sections 13933 and 14301 regarding complex care services under the HCBS New Opportunities Waiver. Effective June 20, 2019, 2019 LA REG TEXT 519682 (NS) makes amendments regarding the Community Choices HCBS waiver. On November 20, 2019, 2019 LA REG TEXT 540354 (NS) provided notice of intent to make amendments regarding home and community-based behavioral—health service waiver—coordinated system of care discharge criteria. Maryland On February 1, 2019, 2019 MD REG TEXT 515991 (NS) provided notice that the Maryland Department of Health (MDH) is amending the Community Pathways Waiver, Family Supports Waiver, and Community Supports Waiver programs which provide various home and community-based services to support participants as they work toward individually defined life outcomes, self-determination, community living, socialization, and economic self-sufficiency. On June 7, 2019, 2019 MD REG TEXT 525802 (NS) and 2019 MD REG TEXT 525804 (NS) provided a general notice that the Maryland Department of Health (MDH) is amending the Community Pathways Waiver, Family Supports Waiver, and Community Supports Waiver. On June 21, 2019, 2019 MD REG TEXT 526679 (NS) provided notice that the Maryland Department of Health (MDH) is amending three waiver programs: Community Pathways Waiver, Family Supports Waiver and Community Supports Waiver. On July 5, 2019, 2019 MD REG TEXT 527895 (NS) provided notice that the Maryland Department of Health (MDH) is amending three waiver programs: the Community Pathways Waiver, Family Supports Waiver and Community Supports Waiver. Massachusetts Effective February 8, 2019, 2019 MA REG TEXT 507128 (NS) amends 101 CMR 359.00 regarding rates for two new Home & Community-Based Services (HCBS) waiver services, “Community Based Day Supports” and “Community Support and Navigation,” that were added to the federally approved HCBS waivers. Missouri Effective July 30, 2019, 2019 MO REG TEXT 515874 (NS) establishes requirements for settings in which home and community-based services are provided under a 1915(c) HCBS waiver program. Effective July 30, 2019, 2019 MO REG TEXT 515873 (NS) implements home and community-based services waiver definitions. New Mexico Effective July 1, 2019, 2019 NM REG TEXT 515684 (NS) amends the New Mexico Administrative Code (NMAC) rule 8.314.3 NMAC, Medically Fragile Home and Community-Based Services Waiver Services. New York Effective May 29, 2019, 2019 NY REG TEXT 518978 (NS) establishes a regulatory framework for delivery and support of HCBS in a way that encourages and supports the service recipient. Ohio Effective January 1, 2019, 2018 OH REG TEXT 506692 (NS) and 2018 OH REG TEXT 506693 (NS) amend, rescind and adopt various provisions regarding home and community-based waiver services regarding PASSPORT, nursing facilities and home care. Effective January 1, 2019, 2018 OH REG TEXT 504726 (NS) amends provisions regarding the MyCare Ohio HCBS Waiver Program. Effective July 1, 2019, 2019 OH REG TEXT 521105 (NS) amends provisions regarding PASSPORT and Assisted Living home and community-based service waivers. Effective July 1, 2019, 2019 OH REG TEXT 521522 (NS) rescinds and adopts provisions regarding Community-Based Services Programs, the MyCare Ohio Waiver and the 1915(i) Specialized Recovery Services Program. Effective July 1, 2019, 2019 OH REG TEXT 521520 (NS) amends provisions regarding Home and Community-Based Services Waivers; Documentation and Payment for Services Under the Individual Options and Level One Waivers; Assistive Technology Under the Individual Options, Level One, and Self-Empowered Life Funding Waivers. On October 1, 2019, 2019 OH REG TEXT 535564 (NS) proposed to amend sections regarding the Medicaid Home and Community- Based Services Program - Individual Options Waiver, Self-Empowered Life Funding Waiver, and Level One Waiver. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -5- On November 18, 2019, 2019 OH REG TEXT 536986 (NS) issued revised filings regarding amendments to rules for home and community-based services waivers - documentation and payment for services under the individual options and level one waivers. On November 27, 2019, 2019 OH REG TEXT 537210 (NS) issued revised filings regarding the adoption and amendment of rules regarding home and community-based waiver services for persons with developmental disabilities. Oklahoma Effective September 1, 2019, 2019 OK REG TEXT 512277 (NS) updates assisted living rules regarding Home and Community-Based Services (HCBS) Waivers for visitation in residential HCBS settings. Effective September 1, 2019, 2019 OK REG TEXT 512284 (NS) revises provisions regarding employment services through home and community-based service waivers. Texas On November 1, 2019, 2019 TX REG TEXT 538290 (NS) provided notice that the Texas Health and Human Services Commission (HHSC) is submitting to the Centers for Medicare and Medicaid Services (CMS) a request to amend the Home and Community-based Services (HCS) waiver administered under section 1915(c) of the Social Security Act. CMS has approved this waiver through August 31, 2023. The proposed effective date for the amendment is March 9, 2019. Utah Effective July 2, 2019, 2019 UT REG TEXT 529979 (NS) provided a notice of continuation for home and community-based service waivers. Washington On February 6, 2019, 2019 WA REG TEXT 516170 (NS) provided notice of a preproposal to amend various sections regarding DDA home and community-based service waivers. Traumatic Brain Injuries Selected Legislation Iowa On February 6, 2019, 2019 IA H.F. 294 (NS) was introduced. If adopted, it will require the department of human services to eliminate the monthly budget maximum or cap for individuals eligible for the Medicaid home and community-based services brain injury waiver. [FN3] On May 3, 2019, 2019 IA H.F. 570 (NS) was adopted. It relates to the brain injury home and community-based services waiver monthly budget maximum. Selected Administrative Activity Indiana On September 4, 2019, 2019 IN REG TEXT 533070 (NS) provided notice of proposed amendments to the aged and disabled waiver and to the traumatic brain injury waiver. Medicaid Expansion or Reform Federal News Trump Administration Appeals Medicaid Work Rulings The Trump administration is appealing recent rulings by a federal judge blocking work requirement for certain low-income people on [FN4] Medicaid. Those rulings impacted requirements for able-bodied adults in Arkansas and Kentucky to work, study, volunteer or perform other community engagement activities. Arkansas has also filed an appeal, where a work requirement was already in effect. Judge James Boasberg ruled that work requirements created obstacles for poor people to access healthcare, which federal and state officials failed to sufficiently evaluate or resolve. The Trump administration argues that such requirements promote health and officials said they will continue approving such requests. State News © 2020 Thomson Reuters. No claim to original U.S. Government Works. -6- Study: Medicaid Expansion Increased ER Use A recent Brookings Institution study has found that Medicaid expansion has driven significantly more patients to hospital emergency [FN5] departments for non-urgent conditions. This finding follows an April JAMA study and appears to rebut initial predictions that expansion would decrease reliance on emergency rooms for non-emergency care. The study looked at the number of hospital visits by each person who gained Medicaid insurance after the expansion, and where those visits were concentrated. Overall, the new Medicaid patients visited hospitals 20% more than they did before they got coverage, and they mostly opted for emergency departments. This is likely the result of the emergency care mandate placed on hospitals, known as EMTALA. Emergency departments cannot reject a patient that is not able to pay, so Medicaid patients do not have to fear debt collection. Also, visits to the ER might be more convenient since patients do not have to find a physician that accepts a particular plan. According the study, “Medicaid expansion effectively lowers the price of an ED visit for the patient, and so we would expect for an increase in visits for those that are discretionary.” Overall, the study did not find an increase in actual emergency visits to ERs. In addition, expansion programs were found to vary significantly across the 20 states studied. Some states saw big shifts in utilization rates, while others saw little. States' ability to target coverage to people who needed it most “varied meaningfully.” Arizona First State to Exempt Native Americans from Work Requirement Recent federal approval of Arizona's request to impose work requirements means that 120,000 of the state's 1.8 million residents on [FN6] Medicaid, ages 19 to 49, must work or volunteer at least 80 hours a month. However, recipients belonging to federally recognized Native American tribes will be exempt. Arizona is now the only state to recognize such an exemption. Arizona initially wanted to exempt all Native Americans. CMS pushed back, citing equal protection concerns. Tribes disagreed with CMS, arguing that it ignored Supreme Court precedent allowing different treatment, disregarded the Constitution and violated treaties. After negotiations, Arizona limited its request to federally recognized tribes, which was granted. CMS explained that the current exemption request is consistent with tribes' status as political entities. Arizona has 21 federally recognized tribes whose reservations take up about a quarter of the state. Now that the Trump administration has granted Arizona's request and set a precedent, it is expected to grant the same exemption for other states that seek one. Arizona Suspends Medicaid Work Requirement The Arizona Health Care Cost Containment System, the state's Medicaid program, said it is temporarily delaying implementation of its [FN7] work requirement “to avoid disruptions and protect Arizona's most vulnerable members.” This decision comes as federal courts have taken a dim view of similar mandates in other states, such as Arkansas and Kentucky, where work requirements were blocked. Some states have taken their own initiative, including New Hampshire, which suspended its work requirement, and Maine, whose new Democratic governor dropped its plan. Arizona officials said their decision was not made in response to specific developments and that they are still committed to eventually implementing work requirements. 17K Arkansans Have Lost Medicaid Coverage Due to Work Requirements Around 17,000 Arkansas Medicaid recipients have lost coverage because they did not comply with work requirements that were [FN8] instituted last August. 12,000 recipients lost coverage in the first three months of the program. In the last month alone, coverage was terminated for 4,655 people because they did not work the required 80 hours or failed to report for three straight months. Those who lost coverage in 2018 can reapply on January 1, 2019. Judge Blocks Work Requirements in Arkansas and Kentucky U.S. District Judge James Boasberg overturned the Trump administration's approval of Medicaid work requirement plans in Kentucky [FN9] and Arkansas, ruling that HHS failed to adequately consider the extent to which the plans would cause people to lose coverage. The ruling is considered a setback to the Trump administration's efforts to scale back Medicaid. The plaintiffs' lawyer, Sam Brooke, praised the decision: “the court reaffirmed the rights of financially insecure individuals to access health care.” Adam Meier of the Kentucky Cabinet for Health and Family Services criticized the ruling as “illogical” because it did not consider how the program was helping state enrollees. Meier said Kentucky is currently considering next steps, including appeal. Arkansas Governor Asa Hutchinson (R) said he was disappointed by the ruling. This marks the second time that Boasberg has vacated the approval of an HHS waiver for Kentucky's work requirements. The previous occurrence was in June 2018. HHS sought to address the coverage issue by arguing that the initial loss figure of 100,000 people would be dwarfed by 450,000 people if the state repealed its expansion. This argument did not sway Boasberg, who said it would justify approval of any plan “as long as it is accompanied by a threat that the state will de-expand.” © 2020 Thomson Reuters. No claim to original U.S. Government Works. -7- Study: Arkansas Medicaid Work Requirement Backfired The Arkansas Medicaid work requirement has been described as backfiring by a new study from the New England Journal of Medicine, which found that the requirement caused thousands of poor adults to lose coverage without evidence that the target population gained [FN10] jobs. The requirement had little chance of succeeding since about 97% of eligible residents aged 30-49 were already employed or should have been exempt. The state mandate resulted in 18,000 of the 100,000-targeted people to fall off Medicaid rolls. Despite officials' statements that many of those individuals may have found jobs, the study found no evidence they secured jobs or coverage. In fact, a noticeable dip in the employment rate was found among those eligible for Medicaid. Additionally, the uninsured rate increased among those aged 30-49 years old from 10.5% in 2016 to 14.5% in 2018, while the employment rate fell from 42% to 39%. The study is the first to provide direct evidence that Arkansas' work requirement left people uninsured and did not promote employment as intended. It also found that a “lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of individuals lost coverage.” At a minimum, researchers think that the state should “pump the brakes” on the program. Study: Non-Expansion Cost Lives in Florida The Center on Budget and Policy Priorities has released a report, which is one of the first to show a connection between lower morality [FN11] rates and states that have expanded Medicaid. In found that between 2014 and 2017, 19,200 people gained access who would have otherwise died. Florida had the second-worst death total (2,776) behind Texas (2,920) during that same time period attributed to not expanding Medicaid. Alison Yager from the Florida Health Justice Project said the results are not surprising to anyone who has studied the “coverage gap,” which is when an individual earns too much to be eligible for Medicaid, but not enough to qualify for subsidies to buy a plan through the federal marketplace. An estimated 850,000 Floridians fall into this gap. “What the report shows for the first time is the scale of the impact of that access and just how many lives are truly saved or lost because of the ability to connect to care and maintain that connection to care, particularly for people who have chronic conditions,” Yager said. The report builds on existing data showing that Medicaid access increases use of medication to control chronic conditions and boosts early detection for cancers responsive to treatment. Researchers examined social security records and found a “tremendous inequality in health by income” in which those at the top level of income distribution can expect to live 15 years longer those at the low end. Previous studies relied on death records that did not have income information. Medicaid expansion has been a non-starter in Florida since 2015. An expansion bill has been filed again this year, containing a compromise that would increase eligibility in exchange for imposing additional work requirements. Experts predict its chances of passage are slim-to-none in a Republican-controlled legislature. Georgia Governor Seeks Medicaid Waiver Georgia Governor Brian Kemp (R) said his administration is considering options to improve access to government-funded health [FN12] insurance for the state's poor and middle class, which could involve seeking a federal waiver for a partial Medicaid expansion. Kemp's administration has budgeted $1 million to hire a consulting team to investigate the best option, mine statistical and population data, and begin the bureaucratic work of navigating the process with federal decision-makers in Washington. The move is politically risky for Kemp. While some state Republicans favor leveraging the ACA to help rural communities, some fear expansion will leave taxpayers on the hook if federal funding wanes in the next few years. Kemp's advisors said he wants to see a range of options and alternatives, including the addition of a work requirement. A potential waiver is expected to be submitted and approved by 2020. Georgia Governor Signs Medicaid Waiver Bill Georgia Governor Brian Kemp (R) signed legislation allowing his administration to pursue two separate federal waivers that would ease [FN13] healthcare access for poor and middle-class residents and set a path toward limited Medicaid expansion. Kemp is prohibited by the bill from pursuing full Medicaid expansion, which he has opposed anyway, but it gives him broad latitude to significantly alter the state's healthcare system. The waiver bill allows Kemp to implement any change allowed by Medicaid if approved by the federal government. However, changes are subject to a complicated, behind-the-scenes process that involves hiring a consultant to craft a plan, negotiating with health officials and politicians, mining statistical data and navigating the bureaucracy in Washington before it has a chance to become a part of the state's health care fabric. Future actions by the Kemp administration will be scrutinized by state Democrats, who have criticized the decision to put aside $1 million for a consultant rather than embracing full expansion, which would cover more people, possibly cost less and spur economic growth. They also argue that the waiver process betrays the legislative branch, which until recently has had final say on any expansion attempts. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -8- Kemp is expected to pursue elements of waivers used in other states, such as funding caps, work requirements and a high-risk pool for ACA insurance. The law set a deadline of June 30, 2020 to apply for the Medicaid waiver. Funding Uncertainties Loom Over Georgia Medicaid Expansion Waiver Georgia Governor Brian Kemp (R) is planning to submit a Medicaid waiver requesting that the federal government fund 90% of the [FN14] state's limited Medicaid expansion. Currently, Georgia receives a 67% funding match. It is feared that fewer people will be covered if this request is denied and the state is forced to shoulder more of the financial burden. CMS administrator Seema Verma has said that the 90% proposal is on the table and has not been ruled out. However, Utah's waiver request with similar limits was recently rejected by the Trump administration. Anonymous White House sources said they believe that no state would receive a 90% match. While Utah officials have floated the idea of full expansion, Georgia has refused to do so. Critics of Kemp's plan argue it would cost the state more while covering fewer people than full expansion. “We estimate this type of waiver would cost about three times as much to cover each patient compared to if we did the full increase,” Laura Harker, a health policy analyst at the Georgia Budget and Policy Institute, said at a Senate hearing in February. Supporters say the goal of the plan is to transform the system and encourage people to move off Medicaid, rather than simply expanding coverage. Georgia Plans for Limited Medicaid Expansion [FN15] Governor Brian Kemp (R) is set to detail a waiver proposal that could lead to limited Medicaid expansion in Georgia. The governor has long ruled out full expansion, which he sees as too costly, but has been open to a more scaled-back program. The Kemp administration's Medicaid policy seeks to harmonize separate proposals that would lower insurance premiums and undercut the ACA. Premiums would be lowered by setting aside more than $300 million in public money to pay insurance firms to cover high-cost claims. Another $2.7 billion in federal subsidies would be shifted to state control to reduce costs for lower-income policyholders. The waiver needs to withstand federal scrutiny and any money needed to run the waiver program would have to come through the state legislature. A legislator opposing the waiver argues that it “costs more person, covers fewer people and takes longer to get started than a straightforward expansion of Medicaid.” Kemp has also been open to adopting elements of other waivers, such as tying eligibility to jobs, school enrollment or community service, which have recently met strong opposition in federal court. Georgia Governor Unveils Medicaid Expansion Plan Georgia Governor Brian Kemp (R) has released a plan to expand Medicaid to the state's poorest able-bodied adults if they satisfy work [FN16] requirements. Kemp's proposal is more limited than other states—uninsured adults who make no more than the federal poverty level would qualify if they spend at least 80 hours per month working, volunteering, job training or attending school. Recipients would also have to pay monthly premiums. The proposal will require approval from the Trump administration. Kemp calls the approach a “conservative reform” that reflects the state's values as a place that “honors work” and “champions individual responsibility.” Critics argue that barriers make the proposal impractical and ineffectual. The governor is moving forward despite legal challenges towards similar plans in other states. Georgia is one of 14 states that have not fully expanded Medicaid. Full expansion would cost the state more than $1.5 billion for the first five years. This plan would seek a more limited expansion, meaning a 90% match that would cost the state $10 million in the first year. Kemp's plan is estimated to cover 52,000 people in its fifth year, as opposed to 500,000 under full expansion. Idaho Introduces Work Requirement Bill [FN17] A Medicaid work requirement bill has been introduced in the Idaho House Health and Welfare Committee. It would require a 20- hour work week minimum, while also mandating that those between 100 percent and 138 percent of the federal poverty level continue paying for private insurance on the state-run health exchange. This is one of many proposals by state Republicans to add sideboards to the voter-approved initiative expanding Medicaid coverage to those who previously earned too much to qualify but too little to afford private insurance on the state health care exchange. Previous versions gave enrollees the choice to move to Medicaid, but supporters of the current version felt that compelling them to stay on the exchange would be better for the state financially. Critics of the measure are concerned about whether barring those people from Medicaid would create a secondary coverage gap and push the burden of covering emergency health care costs to the counties, via the state's catastrophic health care fund. Last year a grass-roots effort put Proposition 2 on the ballot to expand Medicaid, and it passed overwhelmingly, with 61% in favor. Feds Partially Reject Idaho Medicaid Expansion Waiver Request A part of Idaho's Medicaid expansion waiver request, which would allow newly-eligible residents to buy private insurance using federal [FN18] tax credits, has been rejected by CMS because the plan would be too costly for the federal government. Following voter-approval of expansion last November, a state law was passed this year requiring that waiver applications be submitted for various proposals, including work requirements. There is disappointment and surprise amongst Idaho Republican officials. They © 2020 Thomson Reuters. No claim to original U.S. Government Works. -9- worked closely with federal agencies throughout the process and claim that at no point was an indication made that the state's cost neutrality guardrail would be insufficient. While supporters believe the plan would save the state money, critics argue that significant differences between Medicaid and private insurance would create problems, such as disparate covered services and out-of-pocket costs. The Department of Health and Welfare is also now taking public comment on a second possible waiver regarding work requirements. [FN19] Iowa Work Requirement Bill Passes in Senate The Republican-controlled Iowa Senate voted 32-17 along party lines to advance a bill that would require some Medicaid patients to [FN20] work to receive benefits. The bill will now move to the Republican-controlled House, where its future is unclear. The measure, if it becomes law, would require weekly work hours for Medicaid recipients but carves out people with physical and mental conditions. Of the 166,000 enrolled in Medicaid expansion in the state, it is estimated that more than 70,000 may require review and be subject to work requirements. An Iowan enrolled in Medicaid would have one of several options: • Work 20 hours or more per week, averaged over a six-month period • Comply with a work program for 20 hours or more per week, average on a monthly basis • Volunteer 20 hours or more per week, average on a monthly basis • Meet a combination of work and work program participation requirements • Participate in other eligible program activities. Those who do not meet the requirements during an initial 6-month period of eligibility would be terminated for rest of the benefit year. There are multiple exemptions, which include: a woman who is pregnant; a parent or caretaker responsible for a child under six years old, a child with a disability, an elderly person or someone with a medical condition; someone in a drug or alcohol treatment and rehabilitation program or involved in other exempt activities. Implementation would cost nearly $5 million in its first year and nearly $12 million in the second, with the federal government picking up additional expenses. Kansas Medicaid Expansion Stalled After Governor Laura Kelly (D) was elected last November largely on the issue of Medicaid expansion, along with a newly empowered [FN21] coalition of liked-minded Democratic and moderate Republican legislators, expansion seemed inevitable. However, a bill that would have enacted expansion never reached the senate floor since a handful of Republican leaders blocked its progress by linking it to the welfare state and “the abomination of Obamacare.” As a result, Kansas remains as one of the fourteen states yet to expand their Medicaid program. Despite the fact that a Kaiser poll from last November showed a 77% support of Medicaid expansion, holdout politicians are deploying a new playbook like that used here to prevent the adoption of the measure: slow-walking bills, undermining grassroots ballot measures or utilizing procedural roadblocks, then adding provisions with a conservative twist that make passage unlikely. Advocates say they will try expansion again next year. Kentucky Delays Start Date for New Medicaid Work Rule [FN22] Kentucky officials are delaying the start time of some new eligibility rules for a portion of its Medicaid recipients. One of the eligibility rules is a work requirement, otherwise known as “community engagement,” was announced to begin no sooner than July 1. A federal judge blocked this rule last year, but the Trump administration approved it a second time last November. Federal Court to Hear Case on Kentucky Medicaid Work Requirement A federal appeals court is set to decide if Kentucky and other states are allowed to enact work requirements for some low-income [FN23] adults added to the Medicaid rolls via expansion. Under the new requirement, enrollees must report work or volunteer hours, pay premiums and meet other new rules. Kentucky was the first state to win federal approval for such a Medicaid overhaul. The appeals court's panel of judges will determine whether or not it agrees with a lower court ruling that the plan proposed by Kentucky Governor Matt Bevin (R) violates federal Medicaid law. The appeals court will also hear arguments from Arkansas, whose Medicaid work requirement proposal was overturned in March by a federal judge because the state failed to show that the changes would advance the central goal of Medicaid: ensuring coverage to the most vulnerable citizens. This decision could have far-reaching implications. 15 other states have either won approval to enact work requirements or are currently seeking permission to do so. Lawyers for the U.S. DOJ and Governor Bevin are asking the appeals judges to reinstate Kentucky's plan. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -10- Health law advocates argue that the plan violates federal Medicaid law, which includes no provision for work requirements and would cause thousands to lose coverage. Critics also point to data showing that 97% of Kentucky adults covered by Medicaid already meet the proposed requirements or qualify for an exemption. They argue that they policy will compel few beneficiaries to work. Kentucky Governor-Elect Vows to Rescind Medicaid Work Requirements Kentucky Attorney General Andy Beshear (D), who has claimed victory in the state's recent gubernatorial election, is vowing to rescind [FN24] Medicaid work requirements during his first week in office. Current Governor Matt Bevin's (R) waiver request to impose work requirements was approved last year by the Trump administration. However, ongoing litigation has prevented the policy from taking effect. Medicaid expansion was an issue of contention during the election. Andy Beshear's father, former Governor Steve Beshear (D), expanded Medicaid in 2014 to an additional 400,000 low-income adults. Louisiana House Seeks to Expand Medicaid Coverage for Children Louisiana House lawmakers are proposing to expand the state's Medicaid program to include more children with disabilities whose [FN25] parents' income exceeds current eligibility criteria. The legislation would require federal approval and would give children access to home and community-based services. It is estimated that around 1,600 more kids would be eligible. After being approved unanimously in the House, the measure moves to the Senate. Maine Governor Signs Order to Expand Medicaid On her first day in office, newly inaugurated Governor Janet Mills (D) signed an executive order directing the Maine Department of [FN26] Health and Human Services to begin implementing voter-approved Medicaid expansion. Mills' predecessor, Paul LePage (R) repeatedly opposed expansion, even after it received ballot approval by voters in 2017. Mills directed DHHS to partner with health care providers and patients to provide a communications and outreach strategy to help enroll eligible Mainers to speed up application processing. She also submitted a letter to federal regulators laying out implementation plans and answering questions raised about an expansion plan submitted by LePage's administration after a state court judge denied his attempt last month to stall an earlier ruling ordering his administration to implement the law. Funding expansion will now by the primary issue. When Mills was attorney general last year, she proposed using tobacco settlement money. A legislative plan that incorporated some of that money was vetoed by LePage. Mills said she will submit a sustainable funding plan later this month to the legislature as part of her two-year budget proposal. Expansion is projected to cost the state $55 million in its first year. Democrats have suggested that a $37.7 million Medicaid fund surplus be used to pay short-term costs. Mills said she is studying LePage's request to attach work requirements and other eligibility limits, which was approved by the Trump administration last month. However, Mills could still pull out of that waiver. Maine Governor Rejects Medicaid Work Requirements Governor Janet Mills (D) has rejected new Medicaid work requirements that were requested by former Governor Paul LePage (R) and [FN27] approved by the Trump administration just days before LePage left office. Mills informed CMS that Maine would not accept the terms of the pending 1115 Medicaid waiver, which she had wide latitude to accept or reject as the new governor. Instead, according to a news release, the governor has “directed Acting Commissioner of Labor Laura Fortman and Acting Commissioner of Health and Human Services Jeanne Lambrew to make available vocational training and workforce supports to MaineCare participants at every opportunity while increasing access to needed services that keep people in the workforce.” Mills was concerned that the likely result of the waiver would be to leave more residents uninsured without improving workforce participation. Instead of work requirements, Mills plan to expand job training programs for Medicaid recipients. Michigan Medicaid Work Requirement Approved by Feds The Trump administration has approved Michigan's request to require some low-income Medicaid recipients to prove they are working, [FN28] trying to find work or participating in training. The work requirement applies only to certain able-bodied adults between the ages of 19 and 62 who already earn above the federal poverty level. It would require them to report at least 80 hours a month of work or training activities to keep their coverage. It is estimated to apply to more than 500,000 of the approximately 655,000 people in the Michigan program. Anyone failing to report the required hours over the course of three months in a given 12-month period, however, could lose their coverage for at least a month and could regain the coverage only after proving compliance. However, with the program set to go into effect on Jan. 1, 2020, it will be up to the incoming governor, Gretchen Whitmer (D), who opposed the work requirement proposal, to put into place a system. Emily Schwarzkopf, senior policy analyst for the Michigan League for Public Policy, said Whitmer has little choice but to implement it while looking for ways to ensure that people do not get penalized for simply misunderstanding or under-reporting their activities. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -11- Michigan Medicaid Work Requirement Challenged in Lawsuit Four Michigan Medicaid expansion enrollees have brought a federal lawsuit arguing that the Trump administration lacks authority to [FN29] approve rules that would impose work requirements. The suit is asking that the state's work requirements be declared illegal and blocked from implementation. Beginning January 1, 2020, able-bodied adults aged 19 through 61 must show workforce engagement average 80 hours per month if they wish to remain eligible in Michigan's Medicaid expansion program. This is expected to impact more than 270,000 of 670,000 expansion participants. Many recipients would be exempt, including more than 1.7 million covered by traditional Medicaid. An estimated 61,000 to 183,000 could lose coverage starting May 1. Michigan is one of nine states with approved work requirements. Missouri Groups Advocate for Medicaid Expansion Ballot Measure Hospital groups, physicians, patients and business executives are launching a campaign in Missouri to put Medicaid expansion on the [FN30] 2020 ballot. At least 172,000 signatures will be needed for the measure to qualify for the ballot. So far, the campaign has received significant financial backing from the Fairness Project, a D.C.-based nonprofit. The Fairness Project hopes that the movement can build off success from the pro-health wave 2018 election. The Missouri Hospital Association, another supporting organization, said rural hospitals particularly need Medicaid expansion to stay open. Nine rural hospitals have closed in the state since 2014. Even if the measure qualifies and is approved by voters, it will not be a done deal. Other states, such as Maine, Utah and Idaho have approved expansion but later balked at implementation or tried to slim-down the program. Lessons Learned After Failed Medicaid Expansion Initiative in Montana Of the four red states that attempted to pass Medicaid expansion-related initiatives this past November via the ballot, Montana's was [FN31] the only one that failed. It was an attempt to continue expansion in the state. Many think the reason the initiative failed was due to a tactical decision to link continued expansion with increasing the state's tobacco tax. While supporters thought this strategy would boost their efforts with voters, it also attracted Big Tobacco, which has very deep pockets. Nearly $19 million was spent by opponents of the measure, while supporters were only able to spend about $9.7 million. In other words, supporters simply could not keep up. Tobacco interests got too far ahead and blitzed the airways with numerous anti-expansion advertisements. Tobacco interests did not go anywhere near other expansion efforts in Idaho, Nebraska and Utah. Those initiatives all passed comfortably, while Montana's failed 53% to 47%. Instead of presenting voters with a clear expand or not-expand choice, Montana threw an unrelated choice into the mix. According to Adam Searing, an associate professor at the Georgetown Center for Children and Families: “basically it seems the more you focus on that central issue of expanding affordable health care to more working-class people, the more successful you are likely to be.” Montana Legislature Approves Medicaid Expansion Continuation A long-contested bill to continue Medicaid expansion in Montana has passed the state legislature and is headed to the desk of [FN32] Governor Steve Bullock (D), who says he intends to sign it. Medicaid expansion provides health coverage for 96,000 low income adults in Montana. Since it was originally passed in 2015, expansion has been credited with cutting the state's uninsured rate in half. To achieve some level of Republican support and continue the program, some changes were needed. The biggest change is a community engagement requirement that enrollees either work or perform acts of public service for 80 hours per month. Democrats opposed a work requirement, while it was a necessity for Republicans. Some Republicans opposed the bill because they thought the work requirement was too weak and contained too many exemptions. It is expected that the work requirement will result in more than 4,000 residents losing coverage. The bill is projected to go into effect July 1, 2020. Montana Medicaid Expansion Renewal Bill Signed Montana Governor Steve Bullock (D) has a signed the Medicaid Reform and Integrity Act into law, which renews Medicaid expansion [FN33] in the state with added work and public service requirements. When expansion was passed four years ago, Republicans were not allowed to include such requirements under Obama administration rules. The governor signed the bill while calling it “imperfect.” Republican supporters of the requirement, such as Rep. Ed Buttrey, said “skin in the game was always a point that if you benefit from the program, you need to help contribute to the success and funding of the program.” However, there was intra-party disagreement among state Republicans about what the work requirements should look like. Some have criticized the new requirements as weak. State Democrats were initially opposed to any type of work requirement, but without Republican support the expansion program did not stand a chance of being reauthorized and would have expired at the end of July. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -12- Regarding the added work requirements, Montana Budget and Policy Center analyst Heather O'Loughlin says, “it's important to note that we could see a loss of coverage of those that are currently enrolled accessing health care coverages.” However, for the vast majority of recipients, O'Loughlin said coverage will continue with little change. Of the current 96,000 people covered under expansion, around 4,000 are expected to lose coverage. The new requirements will need approval from federal Medicaid officials and could face legal challenges in the meantime. Delay Expected for Start of Nebraska Medicaid Expansion Nebraska's Department of Health and Human Services announced that the state's voter approved Medicaid expansion will not go live [FN34] for another 18 months on October 1, 2020. Eligible recipients might also have to meet work requirements, if enacted between now and the implementation date. Expansion supporters criticized the postponement as a delay tactic that will hurt those who are newly eligible under the measure. They point to other states that expanded their Medicaid programs in much less time, such as Louisiana and Virginia, which expanded in less than 6 months. State officials defended the plan, saying “it is better for our fellow citizens that we carefully and methodically administer the expansion” so that it is “fully functional and viable” on the first day. They also argue that a delay is necessary to upgrade computer software, hire additional workers and negotiate additional contracts with groups that will serve the new Medicaid recipients. The proposal creates two tiers of coverage: a “basic” plan for all newly qualified recipients, and “premium” coverage that's only available to people who are working, in school, volunteering or caring for a relative. The department will eventually be required to submit a state Medicaid plan amendment to the federal government. Lawsuit Challenges Nebraska Medicaid Expansion Delay Advocacy group Nebraska Appleseed has filed a lawsuit seeking court action that would require the state to implement Medicaid [FN35] expansion this year, instead of a delayed date as planned by Governor Pete Ricketts' (R) administration. This suit is on behalf of two individual who are eligible for coverage under expansion, which was approved by voters last November. The Nebraska Department of Health and Human Services announced in April that expansion for some 90,000 uninsured residents would not be implemented until October 1, 2020. Administration officials defend the decision, citing that federal approval is still pending and that other steps must be completed first, such as technology buildouts, contract negotiations and regulatory changes. Appleseed argues that the state is ignoring voter intent by the long delay with complex tiered benefit plans and work requirements. It is also concerned that delayed implementation would mean a failure to capture around $149 million in federal funds for the program, since reimbursement rates will drop from 93% to 90% on January 1, 2020. The lawsuit seeks to require state officials to open enrollment on or before November 17, 2019. New Hampshire Medicaid Work Plan Approved The federal government has approved a plan that requires some Medicaid expansion recipients to complete at least 100 hours of [FN36] community engagement work each month to keep their coverage. State officials are hard at work nailing down the final rules. It is estimated that between 15,000 and 20,000 people will be subject to the new requirement. However, there will be numerous statutory exemptions, including those participating in drug treatment programs and pregnant women. It is unclear when the work requirement will put into effect. New Hampshire Panel Rejects Medicaid Work Rule Changes [FN37] A bipartisan legislative panel unanimously rejected Trump administration changes to its proposed Medicaid work requirements. However, according to state health commissioner Jeffrey Meyers, the rules can still be implemented despite the panel's objections: “our state statute clearly provides that we are to implement the program in accordance with the terms and conditions of the waiver issued by CMS, and we're going to continue now to implement the program.” The state's original request required certain Medicaid recipients to work, go to school, or participate in community service for at least 100 hours a month. There were also exemptions for parents of young children, people with disabilities and others. Those who fell short could also make up hours the next month. However, CMS limited that safety net in its changes and prohibited anyone working more than 100 hours per month from carrying over that extra time to the next month. With a March 1 start date, June would mark the first month that participants would have to provide proof of employment or other “community engagement” activities. Those who don't meet the requirements would be notified by July 10, and would have the rest of the month to make up for any deficiencies. Under the terms of the plan, no one can be suspended from coverage until August 2019. New Hampshire Senate Advances Bill Attacking Medicaid Work Requirement The New Hampshire Senate approved a bill that would weaken, and possibly eliminate, a work requirement for Medicaid expansion [FN38] enrollees. This move angered Senate Republicans, who see it as a betrayal of compromise reached last session to expand only if a work requirement was attached. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -13- The work requirement would be terminated if more than 500 people are removed from Medicaid as a result. In addition, restrictions would be eased on who will be exempted from the work requirement. The bill will now advance to the Finance Committee. An amendment may be offered to protect the work requirement when it returns to the full Senate. Senate Democrats said they are open to further compromises. Other provisions in the original bill, such as eliminating the work requirement for enrollees over age 50, were scrapped to win more support. New Hampshire Bill Aims to Roll Back Work Requirement A New Hampshire bill is seeking to roll back a work requirement set to take effect this summer, which mandates that certain enrollees [FN39] complete 100 hours of qualifying activities each month or risk losing coverage. If the bill is passed, the work requirement would be suspended if more than 500 people lose coverage because of it. More exemptions would also be added, including for those who are homeless, grandparents who are foster parents and full-time students. Lawmakers supporting the bill say they wanted to avoid a situation similar to Arkansas, where more than 18,000 people lost coverage for non-compliance. The bill passed in the senate on a party-line vote and now awaits a decision by the house. New Hampshire's work requirement is also currently being challenged in federal court. New Hampshire House Passes Bill Easing Medicaid Work Requirement A bill that would weaken work requirements for New Hampshire's Medicaid expansion program passed the state house in a party-line [FN40] vote. It had already been approved by the state senate. However, Governor Chris Sununu (R) will likely veto it. The work requirement would be ended entirely if it resulted in more than 500 people losing their benefits out of 50,000 expansion enrollees. Other restraints include applying it only to people 19 to 49 years of age, reducing required hours worked from 100 to 80 and basing it on an average of 20 hours per week instead of 25. Self-employment and participation in mental illness recovery programs are also added as activities that would satisfy the work requirement. Exemptions would be provided for custodial parents or caretakers has been changed to apply in households with children up to the age of 16, as opposed to under the age of 6 in the existing statute. Any beneficiary who is homeless, the caretaker of a grandchild, a full- time college or university student and anyone 50 or older would also be exempted. The work requirement took effect on June 1, with reporting deadlines in July. New Hampshire Delays Medicaid Work Requirement New Hampshire Governor Chris Sununu (R) is delaying penalties related to the state's Medicaid work requirement after nearly 17,000 [FN41] recipients were found to be out of compliance in the first month of the program. Of the 24,895 Medicaid recipients enrolled in June without a qualifying exemption, 16,874 people failed to provide proof to the state that they met the new Medicaid work rules. Recipients are required to work 100 hours each month or prove some other type of qualifying community engagement. Despite months of outreach by the state, including radio ads, public information sessions, direct mailings and text messages, the work requirement will be delayed for 120 days before being implemented again. Sununu announced that some of the program requirements would be loosened and that a door-to-door effort will be made by state employees to notify recipients of the new rules. New Hampshire Work Requirement Blocked by Federal Judge A federal judge has ruled in favor of a class action lawsuit alleging that the Trump administration exceeded its authority by allowing New [FN42] Hampshire to implement its work requirement. U.S. District Judge James E. Boasberg reasoned that the Trump administration did not adequately address potential coverage loss for low-income residents and that “we have all seen this movie before.” Specifically, plaintiffs argued that the requirement does not further Medicaid's original goals because implementation failures will [FN43] lead to many losing coverage unnecessarily. Officials from the state and Trump administration disagreed, arguing that the work requirement encourages upward mobility and makes the program more fiscally sustainable. The federal judge hearing this case also recently struck down similar requirements in Arkansas and Kentucky, which are being appealed by the Trump administration. New Hampshire to Appeal Medicaid Work Requirement Ruling The New Hampshire Department of Justice has announced it will appeal a federal court decision that struck down the state's Medicaid [FN44] expansion work requirement. The U.S. District Court for the District of Columbia found that the federal government exceeded its authority by allowing the state to include a work requirement onto its expanded Medicaid program. State officials anticipate this appeal will eventually reach the U.S. Supreme Court and that the work requirement will ultimately be upheld. In the meantime, Kentucky and Arkansas, whose work requirements were also vacated by the same court, could have their appeals joined with New Hampshire's. CMS could also issue a new approval after re-application by the state. However, the program is halted for the time being. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -14- North Carolina Medicaid Expansion Bill Expected to Move Forward North Carolina House Speaker Tim Moore (R) anticipates that a Republican Medicaid expansion proposal will get another look soon. [FN45] It would provide for expansion, but with small premiums and work requirements. Governor Roy Cooper's (D) budget did not include these expansion criteria and was recently vetoed by the house. Ohio Work Requirement Request Granted [FN46] CMS has granted the Ohio Department of Medicaid's request to create a work requirement for Medicaid expansion enrollees. Participants would need to have a job or perform community services for at least 20 hours per week, unless given an exemption. Some of the people who will be exempt include those 50 years of age or older; those “physically or mentally unfit for employment”; participants in alcohol or drug addiction treatment; caregivers for a disabled household member; pregnant women; parents or guardians of minor children; those who applied for or receiving unemployment compensation and students who go to school at least half time. The state has estimated that about 95% of those covered by expansion would already either meet the work requirement or be exempt. The Center for Community Solutions, a Cleveland think tank, has questioned the math of how many people will lose coverage. While the state estimated 134,000 recipients would be affected, nearly 400,000 Ohioans no longer receive SNAP benefits. Ohio will need to develop and publish a comprehensive implementation plan that is due within 90 days of federal approval. Within 150 days of federal approval, the state needs to develop and publish monitoring protocols and within 150 days the state needs to develop and publish its monitoring protocol. Ohio Medicaid Work Requirement Calls for Case Worker Contact Ohio Medicaid recipients will not be required to meet work criteria (80 hours per month) to receive coverage until a case worker speaks [FN47] with them first. According to the state's latest implementation plan filing to CMS: “Prior to initiating Medicaid termination, a caseworker must speak directly with the beneficiary over the phone or in person…If, after speaking with the beneficiary, the caseworker determines that the beneficiary should have Medicaid eligibility terminated for non- compliance with the (work) requirement, a pre-termination review will be completed to determine if the beneficiary qualifies for Medicaid under a different eligibility category.” Ohio's Medicaid work requirement plan, which received federal approval in March, is expected to begin January 1, 2021. The state's implementation plan, which spells out how the work requirement will be carried out, also needs federal approval. Ohio Department of Medicaid Director Maureen Corcoran said, “One of the things that the governor [DeWine] was very specific about was making this kind of more individualized – contact with a person, not just cutting people off.” Group Seeks to Put Medicaid Expansion Issue Before Oklahoma Voters A coalition of medical professionals, patients, business leaders, nonprofits and health care advocates are launching a campaign to [FN48] put the issue of Medicaid expansion to voters in Oklahoma. The group supports a plan for the state to obtain around $1 billion annually in federal dollars for expanding the program to some 200,000 residents. About 90% of the expansion would be funded with federal money, but Republican leaders are concerned that state's share would cost too much. 178,000 signatures must be collected by the coalition before the issue can be put on the November 2020 ballot. A conservative think tank challenged the initiative, arguing it unconstitutionally cedes state power to the federal government. However, the Oklahoma [FN49] Supreme Court has rejected the challenge allowing signature gathering to continue. South Carolina Seeks Medicaid Work Requirement Despite ongoing court battles in other states, South Carolina is seeking waiver permission from CMS to impose work requirements on [FN50] Medicaid recipients, who would need to work, be enrolled in job training or attend school for an average of 80 hours a month. Unlike other states that have tried to impose work requirements, South Carolina will not completely end Medicaid benefits for those who do not comply or force beneficiaries to re-enroll in the program if they lose their benefits. Instead, people who cannot meet the requirements for three consecutive months will have their benefits suspended for three months, or until the work requirements are met, whichever comes first. Exemptions would be provided to disabled adults, full-time caregivers, pregnant women, anyone over age 65 and others. A state analysis estimated that 11,000 recipients would lose coverage over the course of the five-year demonstration period. If approved, the requirements would not take effect until at least July 1, 2020. Study: Work Requirement Could Remove 68,000 from Tennessee Medicaid A new study by the Georgetown University Health Policy Institute finds that 68,000 TennCare recipients could be removed from [FN51] Medicaid rolls if a work requirement takes effect. State officials are awaiting federal approval for a plan that would require able- bodied adult recipients to work, volunteer or go to school beginning in 2020. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -15- Researchers based their findings on the results of Arkansas' work requirement. 18,000 of 60,000 recipients impacted lost benefits just five months after the program took effect. The study said it did not expect Tennessee to fair better than Arkansas. While Arkansas exempts all adults in a household with a child under 18 years old, Tennessee will only exempt one parent in home with a child under 6 years of age. TennCare officials are disputing the study, projecting that only 56,000 people will be subject to the plan, meaning fewer than that would lose coverage. The state also argues that many will be exempt from the new requirements, including those subject to work requirements from other public assistance programs. Some recipients may also transition to other forms of insurance if their work earnings increase. Utah Medicaid Expansion Could Be Delayed, Altered Medicaid expansion was approved by Utah voters in November via Proposition 3, which provided for $800 million in funding, combined [FN52] with about $90 million in new state sales tax revenue to provide healthcare for 150,00 low-income residents. However, the April launch date could be moved back and benefits could be available to fewer people than previously thought. According to legislation sponsored by Sen. Allen Christensen (R), “We are going to implement Medicaid expansion. We are going to implement the sales tax increase to help pay for it…but we have to put some bumpers or guardrails around it so that it isn't going to break the bank.” Guardrails would include a cap on Medicaid enrollment and work requirements. Critics of expansion argue that the voter approved Proposition 3 did not provide enough money to accomplish what it claimed to do. Supporters disagree, saying that Proposition 3 provided enough money to address increased healthcare costs. AARP Utah Director Alan Ormsby said a “cushion” of roughly $15 million was built into the initiative's sales tax hike, an increase of 0.15 percent on nonfood items, and that a combination of state and federal funding is sufficient for the initial expansion and future years. Ormsby also criticized imposing work requirements on beneficiaries, saying that it does little to incentivize productivity, causes patients to lose access to health care and imposes costly complications to the administration of Medicaid. A scaled-down expansion plan was approved by lawmakers last year but was superseded by Proposition 3's passage. That plan would have also imposed work requirements on a smaller pool of beneficiaries with no additional state investment. It had yet to be approved or denied by federal administrators. Christensen's current plan would also require a federal waiver. Utah Governor Signs Bill Limiting Voter-Approved Medicaid Expansion Utah Governor Gary Herbert (R) has signed legislation limiting the state's Medicaid expansion plan, which defies voters who approved [FN53] full expansion under Proposition 3 last November. The new law is projected to cover 48,000 fewer people at an increased cost of $50 million. The state will be required to submit a waiver asking for the Trump administration's permission to implement a partial expansion for people earning up to 100% of the federal poverty level (rather than the ACA's prescribed 138%). Individuals earning between 100-138% of the federal poverty level will be required to purchase coverage on the exchange. Other changes include an enrollment cap and a work requirement. The new plan is set to be implemented on April 1. If the waiver is not approved, the legislation requires the program to revert to full expansion with certain restrictions. Utah Medicaid Work Requirements Approved The Trump administration approved Medicaid work requirements in Utah, just days after similar measures were struck down in [FN54] Arkansas and Kentucky. In in its approval, the administration acknowledged that Utah residents might lose coverage, but that others would become healthier and gain financial independence. Utah voters approved a full Medicaid expansion plan last November. Under the new program, 70,000 to 90,000 adults will become eligible for Medicaid. A unique feature allows the state to freeze enrollment of newly eligible beneficiaries if the projected costs of their coverage exceed the funds appropriated by the legislature. Seema Verma, head of CMS, defends the enrollment limits as allowing the state to keep within its budget so it will not have to cut benefits. Joan Alker, executive director of the Center for Children and Families at Georgetown University, criticizes the enrollment freeze option as being “in direct conflict with Medicaid's guarantee of coverage if you meet the income eligibility requirements. As a legal matter, it is even more questionable than the waivers struck down in Arkansas and Kentucky.” The Arkansas and Kentucky waivers were struck down because they could not be justified as contributing to either the financial independence of Medicaid beneficiaries or the “fiscal sustainability” of the program for a state. However, those rulings are not binding on federal officials as they consider proposals from other states. Feds Reject Enhanced Funding for Utah Partial Medicaid Expansion [FN55] The Trump administration has rejected Utah's waiver request for enhanced federal funding for a partial Medicaid expansion. State officials say that the move will not change the April expansion to additional low-income residents. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -16- In its waiver, Utah asked the federal government to cover a larger share of costs, even though the partial expansion would not extend eligibility to as many people as a general overhaul would have. Earlier this year, state lawmakers scaled back the expansion approved by voters by reducing coverage numbers and adding spending caps. CMS explained that it supports states' efforts “to design innovative Medicaid demonstrations that improve outcomes and promote fiscal sustainability” but that providing enhanced federal funding “would invite continued reliance on a broken and unsustainable ‘Obamacare’ system.” No other state has received federal approval for increased federal money without fully expanding Medicaid. Virginia Medicaid Expansion Has Enrolled 182K Governor Ralph Northam (D) has announced that more than 182,000 Virginians have enrolled in new health coverage under [FN56] expansion. Coverage is available to 19 to 64-year old individuals who are not eligible for Medicare and meet income requirements, which vary by family size. SNAP recipients and parents whose children receive Medicaid coverage are permitted to use a short-form application to sign up by January 4. Virginia Medicaid Expansion Adds 300K Enrollees Governor Ralph Northam (D) has announced that just over 300,000 low-income adults have enrolled in Virginia's expanded Medicaid [FN57] program. Officials estimated that about 400,000 adults would be newly eligible under expansion, which was approved last year. New enrollees are already taking advantage of Medicaid coverage. More than 229,000 have received some type of service, such as seeing a doctor or filling a prescription. Wisconsin Senate GOP Not Ruling Out Medicaid Expansion [FN58] Governor-elect Tony Evers (D) plans to propose in his first budget that the state accept full Medicaid expansion. Outgoing Governor Scott Walker (R) rejected federal Medicaid dollars and instead opted for partial expansion. Senate Majority Leader Scott Fitzgerald (R) said he is not ruling out accepting federal money for expansion, but that he also does not see support for it in the Republican-led legislature. Assembly Minority Leader Gordon Hintz (D) said he thinks there is room for creative compromise, namely if some expansion funds would be used to boost reimbursement rates. However, Assembly Majority Leader Robin Vos (R) is less optimistic, saying she is adamantly opposed to even discussing expansion in the legislature because it will never happen. Fitzgerald said he would like to revisit the question in February when officials have a better idea of the state's financial situation. Wisconsin On August 22, 2019, 2019 WI S.B. 361 (NS) was introduced. If adopted, it will revise Medicaid eligibility criteria to expansion levels. Medicaid Work Bill Moves Closer to Passage in Wyoming A bill that would require able-bodied Wyoming residents to work 20 hours per week to qualify for Medicaid has passed its first reading in [FN59] the house. A similar bill died in the house last year after passing the Senate. Proponents say that only 2-3,000 of the state's 60,000 Medicaid recipients would be impacted. Critics fear that a 6-month lockout provision in the bill could lead to some recipients slipping through the cracks and not getting needed healthcare services. The Medicaid work bill must survive two more votes in the House before heading to Governor Mark Gordon (R), who previously opposed expansion. Medicaid Expansion Bill Advances in Wyoming [FN60] A Wyoming legislative committee has advanced a bill allowing Governor Mark Gordon (R) to expand Medicaid in the state. The Joint Revenue Committee approved the measure, which moves it to the full legislature next February. Under the bill, the governor has to direct the departments of health and insurance to explore expansion options. If expansion is recommended, the legislature must approve even if it means convening a special session. Gordon has not been a supporter of expansion in the past due to its costs, but says he recognizes challenges that residents face trying to afford healthcare. Around 19,000 residents would initially be covered under expansion. Selected Legislation Alaska On March 4, 2019, 2019 AK S.B. 7 (NS) was amended/substituted. If adopted, it will require the Department of Health and Social Services to apply for a waiver to establish work requirements for certain adults who are eligible for the state medical assistance program. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -17- Arkansas On March 26, 2019, 2019 AR H.B. 1923 (NS) was introduced. If adopted, it will ensure that the work requirements for the Arkansas Medicaid Program are updated to include parents, parents currently included under the Arkansas Works Program, and all able-bodied [FN61] adults between 50 and 60 years of age. On April 1, 2019, 2019 AR H.B. 1966 (NS) was introduced. If adopted, it will reinstate coverage in the Arkansas Works Program for [FN62] individuals who lost coverage due to failure to meet the work requirements. Connecticut On January 18, 2019, 2019 CT S.B. 146 (NS) was introduced. If adopted, it will allow the Commissioner of Social Services to seek approval of an amendment to the state Medicaid plan or a federal waiver, if necessary, to exempt pension benefits granted to certain veterans by the United States Department of Veterans Affairs from Medicaid income eligibility criteria as unreimbursed medical expenses. Federal On February 27, 2019, 2019 CONG US S 585 was introduced. If adopted, it will provide the same level of Federal matching assistance for every State that chooses to expand Medicaid coverage to newly eligible individuals, regardless of when such expansion takes place. Florida On March 5, 2019, 2019 FL H.B. 223 (NS) and 2019 FL S.B. 126 (NS) were introduced. If adopted, they will expand Medicaid eligibility [FN63] to specified adults. On March 5, 2019, 2019 FL H.B. 1311 (NS) was introduced. If adopted, it will expand Medicaid coverage for certain individuals by a [FN64] specified date. On March 5, 2019, 2019 FL H.B. 955 (NS) was introduced. If adopted, it will require AHCA to seek federal approval to require Medicaid [FN65] enrollees to engage in work activities to maintain eligibility & enrollment; eliminates premium-sharing requirement. Idaho On March 6, 2019, 2019 ID H.B. 249 (NS) was introduced. If adopted, it will provide that Medicaid eligibility expansion may become null, void, and of no force and effect under certain circumstances. On March 18, 2019, 2019 ID H.B. 277 (NS) was introduced. If adopted, it will amend existing law to establish provisions regarding Medicaid, including work requirements and managed care for persons eligible for Medicaid due to Medicaid eligibility expansion. On March 22, 2019, 2019 ID H.B. 290 (NS) was introduced. If adopted, it will amend and add to existing law to provide funds for Medicaid expansion and other services and to provide exclusions from eligibility for the county medically indigent program and the catastrophic health care cost program. Mississippi On January 14, 2019, 2019 MS H.B. 257 (NS) was introduced. If adopted, it will require the Governor and Division of Medicaid to [FN66] negotiate to obtain a federal waiver to expand Medicaid coverage. On January 21, 2019, 2019 MS H.B. 928 (NS) was introduced. If adopted, it will direct the governor and Division of Medicaid to [FN67] negotiate with the federal government to obtain a Medicaid waiver to create a plan to allow Medicaid expansion. Montana On May 9, 2019, 2019 MT H.B. 658 (NS) was adopted. It generally revises healthcare laws and permanently expand Medicaid. New Jersey On November 18, 2019, 2018 NJ A.B. 5957 (NS) was introduced. If adopted, it will expand Medicaid coverage for certain school-based services. New York © 2020 Thomson Reuters. No claim to original U.S. Government Works. -18- On January 9, 2019, 2019 NY S.B. 933 (NS) was introduced. If adopted, it will direct the commissioner of the department of health to apply for a waiver to implement a work requirement for able-bodied adult recipients of Medicaid. North Carolina On March 28, 2019, 2019 NC S.B. 387 (NS) was introduced. If adopted, it will implement work and community engagement as a contingency to participation in the North Carolina Medicaid program. Ohio On February 26, 2019, 2019 OH S.B. 60 (NS) was introduced. If adopted, it will establish a waiver component for the Medicaid expansion eligibility group and to abolish the Healthy Ohio Program. Tennessee On February 7, 2019, 2019 TN S.B. 1049 (NS) was introduced. If adopted, it will require the bureau to submit to the federal department of health and human services a Section 1115 waiver that would expand Medicaid eligibility to Tennessee residents who suffer from an opioid addiction and earn less than 138 percent of the federal poverty level as long as the eligibility only lasts for the duration of the person's involvement in a substance abuse treatment program approved by the bureau. Texas On February 20, 2019, 2019 TX H.B. 590 (NS) was introduced. If adopted, it will expand Medicaid eligibility to certain persons under the ACA. On March 6, 2019, 2019 TX S.B. 1752 (NS) was introduced. If adopted, it will expand Medicaid eligibility to all persons for whom federal matching money is available. On March 6, 2019, 2019 TX H.B. 3591 (NS) was introduced. If adopted, it will expand Medicaid eligibility to certain persons who are younger than 26 years of age. On March 7, 2019, 2019 TX H.B. 3765 (NS) was introduced. If adopted, it will expand Medicaid eligibility to certain working parents for whom federal matching funds are available. On March 7, 2019, 2019 TX S.B. 1839 (NS) was introduced. If adopted, it will expand Medicaid eligibility for certain veterans and their families. On March 7, 2019, 2019 TX H.B. 3698 (NS) was introduced. If adopted, it will expand Medicaid eligibility in certain counties. Selected Regulations Utah Effective May 7, 2019, 2019 UT REG TEXT 525085 (NS) adopts, via Emergency Rule, provisions of Medicaid expansion set forth in 2019 UT S.B. 96 (NS). Other Waivers State News Tennessee Passes Medicaid Block Grant Bill The GOP-led Tennessee legislature passed a bill ordering the governor to submit a Section 1115 waiver request within six months that would transform the state Medicaid program, TennCare, from an open-ended entitlement program to block grant system with fixed [FN68] payments. This would be the first program of its kind. Governor Bill Lee (R) has indicated he will sign the bill, which is in line with President Trump's policy goal of states experimenting with a capped federal payment system to constrain Medicaid spending growth. Supporters argue a block grant approach enables states to design more efficient programs with better benefits and savings. Opponents warn that capped models will lead to reduced funding over time and require cuts to enrollment, benefits and payment rates. Little information has been given regarding how the block grant will be structured. If the waiver request is approved, litigation will likely be triggered questioning whether CMS has the authority to change the fundamental funding formula without congressional approval. Selected Legislation Arkansas © 2020 Thomson Reuters. No claim to original U.S. Government Works. -19- On March 6, 2019, 2019 AR H.B. 1717 (NS) was introduced. If adopted, it will increase the number of persons served under the [FN69] Assisted Living Waiver program. California On April 25, 2019, 2019 CA A.B. 50 (NS) was amended/substituted. If adopted, it would require the department to submit, in 2019, to the federal Centers for Medicare and Medicaid Services a request for renewal of the Assisted Living Waiver program with specified amendments. Louisiana On June 20, 2019, 2019 LA H.B. 199 (NS) was adopted. It establishes the TEFRA option Medicaid waiver program to serve children with disabilities. Mississippi On January 21, 2019, 2019 MS H.B. 1394 (NS) was introduced. If adopted, it will authorize and direct the Division of Medicaid to seek necessary federal waivers to continue to reimburse for psychiatric services for patients formerly eligible for services at an inpatient [FN70] licensed acute care facility located on the Mississippi Gulf Coast. Montana On April 18, 2019, 2019 MT H.B. 529 (NS) was adopted. It revises requirements related to waiting list for waiver services. New Mexico On January 16, 2019, 2019 NM H.B. 68 (NS) was introduced. If adopted, it will direct the Department of Health to enroll over a 5-year [FN71] period specified numbers of individuals into support services provided through the Medicaid developmental disabilities waiver. Nevada On June 5, 2019, 2019 NV A.B. 223 (NS) was adopted. It requires the Department of Health and Human Services to seek a federal waiver to allow certain dental care for persons with diabetes to be included in the State Plan for Medicaid. Oklahoma On February 4, 2019, 2019 OK H.B. 2443 (NS) and 2019 OK S.B. 386 (NS) were introduced. If adopted, they will direct the Oklahoma Health Care Authority to seek certain Medicaid waiver authority. Texas On February 25, 2019, 2019 TX S.B. 1093 (NS) was introduced. If adopted, it will establish requirements relating to the eligibility of children and prioritization of persons on waiting lists for certain Medicaid long-term care services waiver programs. On March 7, 2019, 2019 TX H.B. 3860 (NS) was introduced. If adopted, it will amend provisions regarding a child's eligibility for the [FN72] Medicaid Buy-In program or the medically dependent children (MDCP) waiver program. On March 7, 2019, 2019 TX H.B. 3747 (NS) was introduced. If adopted, it will enact requirements regarding the eligibility of children [FN73] and prioritization of persons on waiting lists for certain Medicaid long-term care services waiver programs. Utah On March 6, 2019, 2019 UT S.B. 260 (NS) was introduced. If adopted, it will make amendments to the limited support services waiver program. Virginia On March 18, 2019, 2018 VA H.B. 1812 (NS) was adopted. It directs the Department of Medical Assistance Services to amend eligibility criteria for the Intellectual Disability waiver and the Individual and Family Developmental Disabilities Support waiver to allow the dependent of a foreign service member to maintain his position on the waiting list following a transfer of the foreign service member to an assignment outside the Commonwealth, so long as the foreign service member maintains the Commonwealth as his legal residence to which he intends to return following completion of the assignment. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -20- Selected Regulations Ohio Effective October 1, 2019, 2019 OH REG TEXT 528375 (NS) adopts OH ADC 5160-33-03 (Eligibility for the Medicaid funded component of the assisted living waiver program) and OH ADC 5160-33-04 (Enrollment process for Medicaid-funded component of the assisted living waiver program). Wyoming Effective April 30, 2019, 2019 WY REG TEXT 523695 (NS) makes changes, via Emergency Rule, regarding WY ADC 048.0037.46 (Medicaid Supports and Comprehensive Waivers). Effective August 27, 2019, 2019 WY REG TEXT 532595 (NS) adopts provisions regarding Medicaid supports and comprehensive waivers. APPENDIX A Overview The Social Security Act authorizes multiple waiver and demonstration authorities to allow states flexibility in operating Medicaid [FN74] programs. Each authority has a distinct purpose, and distinct requirements. The three primary waivers are: • Section 1115 Research & Demonstration Projects: This section provides the Secretary of Health and Human Services broad authority to approve projects that test policy innovations likely to further the objectives of the Medicaid program. • Section 1915(b) Managed Care/Freedom of Choice Waivers: This section provides the Secretary authority to grant waivers that allow states to implement managed care delivery systems, or otherwise limit individuals' choice of provider under Medicaid. • Section 1915(c) Home and Community-Based Services Waivers: This section provides the Secretary authority to waive Medicaid provisions in order to allow long-term care services to be delivered in community settings. This program is the Medicaid alternative to providing comprehensive long-term services in institutional settings. Section 1115 of the Social Security Act provides the Secretary of Health and Human Services broad authority to authorize experimental, pilot, or demonstration projects likely to assist in promoting the objectives of the Medicaid statute. Flexibility under Section 1115 is sufficiently broad to allow states to test substantially new ideas of policy merit. These projects are intended to demonstrate and evaluate a policy or approach has not been demonstrated on a widespread basis. Some states expand eligibility to individuals not otherwise eligible under the Medicaid program, provide services that are not typically covered, or use innovative service delivery systems. There are two types of Medicaid authority that may be requested under Section 1115: • Section 1115(a)(1) – allows the Secretary to waive provisions of section 1902 to operate demonstration programs, and • Section 1115(a)(2) – allows the Secretary to provide Federal financial participation for costs that otherwise cannot be matched under Section 1903. Projects are generally approved to operate for a five-year period, and states may submit renewal requests to continue the project for additional periods of time. Demonstrations must be “budget neutral” over the life of the project, meaning they cannot be expected to cost the Federal government more than it would cost without the waiver. Section 1915(b) waiver authority allows states to operate programs that impact the delivery system of some or all of the individuals eligible for Medicaid in a state: • by mandatory enrollment of beneficiaries into managed care programs (although states have the option, through the Balanced Budget Act of 1997 to enroll certain beneficiaries into mandatory managed care via a State Plan Amendment), or • creating a “carve out” delivery system for specialty care, such as behavioral health care. Section 1915(b) waiver programs do not have to be operated statewide. They may not be used to expand eligibility to individuals not eligible under the approved Medicaid state plan. States also have the option to use savings achieved by using managed care to provide additional services to Medicaid beneficiaries not typically provided under the state plan. To implement these programs, the Secretary may waive certain Medicaid requirements (statewide, comparability of services, and freedom of choice of provider.) There are four types of authorities under Section 1915(b) that states may request: • (b)(1) mandates Medicaid Enrollment into managed care • (b)(2) utilize a “central broker” • (b)(3) uses cost savings to provide additional services © 2020 Thomson Reuters. No claim to original U.S. Government Works. -21- • (b)(4) limits number of providers for services States may offer a variety of services to consumers under an HCBS waiver program (Section 1915(c)) and the number of services that can be provided is not limited. These programs may provide a combination of both traditional medical services (i.e. dental services, skilled nursing services) as well as non-medical services (i.e. respite, case management or environmental modifications). Family members and friends may be providers of waiver services if they meet the specified provider qualifications. However, in general spouses and parents of minor children cannot be paid providers of waiver services. States have the discretion to choose the number of consumers to serve in a HCBS waiver program. Once approved by CMS, a state is held to the number of persons estimated in its application but has the flexibility to serve greater or fewer numbers of consumers by submitting an amendment to CMS for approval. The State Medicaid agency must submit to CMS for review and approval an application for an HCBS waiver, and the State Medicaid Agency has the ultimate responsibility for an HCBS waiver program, although it may delegate the day-to-day operation of the program to another entity. Initial HCBS waivers are approved for a three-year period, and waivers are renewed for five-year intervals. Provisions Waived Under Section 1915(c ) Section 1902(a)(1), regarding statewideness. This allows states to target waivers to particular areas of the state where the need is greatest, or perhaps where certain types of providers are available. Section 1902(a)(10)(B), regarding comparability of services. This allows states to make waiver services available to people at risk of institutionalization, without being required to make waiver services available to the Medicaid population at large. States use this authority to target services to particular groups, such as elderly individuals, technology-dependent children, or persons with mental retardation or developmental disabilities. States may also target services on the basis of disease or condition, such as Acquired Immune Deficiency Syndrome. Section 1902(a)(10)(C)(i)(III), regarding income and resource rules applicable in the community. This allows states to provide Medicaid to persons who would otherwise be eligible only in an institutional setting, often due to the income and resources of a spouse or parent. States may also use spousal impoverishment rules to determine financial eligibility for waiver services. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN1] . Died in committee. [FN2] . Held in committee for further study. [FN3] . Withdrawn. [FN4] . Trump administration appeals on Medicaid work requirements, AP (April 10, 2019) at: https:// www.apnews.com/2ae55802bed042af81e3d6883d56964b? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=71666000&_hsenc=p2ANqtz-9TES [FN5] . Susannah Luthi, Medicaid expansion increased ED use, study shows, Modern Healthcare (September 5, 2019) at: https://www.modernhealthcare.com/medicaid/medicaid-expansion-increased-ed-use-study-shows? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=76526099&_hsenc=p2ANqtz-8Sq2 hsmi=76526099. [FN6] . Felicia Fonseca, Arizona is only state where tribes avoid Medicaid work rules, ABC News (January 18, 2019) at: https:// abcnews.go.com/beta-story-container/Health/wireStory/arizona-state-tribes-avoid-medicaid-work-rules-60482818. [FN7] . Jonathan J. Cooper, Arizona quietly suspends Medicaid work requirement, AZ Central (October 21, 2019) at: https:// www.azcentral.com/story/news/local/arizona-health/2019/10/21/arizona-quietly-suspends-medicaid-work-requirement/4058397002/. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -22- [FN8] . Nathaniel Weixel, Almost 17K Arkansas have lost Medicaid coverage due to work requirements, The Hill (December 17, 2018) at: https://thehill.com/policy/healthcare/421716-almost-17k-arkansans-have-lost-medicaid-coverage-due-to-work-requirements? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=68419373&_hsenc=p2ANqtz- _EGI0XLdYtk6NlI6Yu1mWch4cBE7pZiDfcB4MXXAy_NG2CRigHT2EgbnH3aHyXZvCUF_ fCIFrKJWguEQdRySfM4S4Ayx2AFxE9dd9I&_hsmi=68419373. [FN9] . Nate Raymond and Dan Whitcomb, U.S. judge blocks Medicaid work requirements in Kentucky, Arkansas, Reuters (March 27, 2019) at: https://www.reuters.com/article/us-usa-healthcare-medicaid-kentucky/u-s-judge-blocks-kentucky-from-implementing-medicaid-work- requirements-idUSKCN1R82G6. [FN10] . Phil Galewitz, Study: Arkansas Medicaid Work Requirement Hits Those Already Employed, Kaiser Health News (June 19, 2019) at: https://khn.org/news/study-arkansas-medicaid-work-requirements-hit-those-already-employed/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=73877862&_hsenc=p2ANqtz-8nUq wvILkG-MDiH_DbRiUGdIoz6dnZjwQZ-wo5i-P9ajT1UlSVJx_tij1ZjfkRxeyGsgHZP49xh2V-o&_ hsmi=73877862. [FN11] . Ben Conarck and Elizabeth Koh, The cost of not expanding Medicaid in Fla.? Nearly 2,800 deaths, a new report estimates, Miami Herald (November 14, 2019) at: https://www.miamiherald.com/news/health-care/article237261439.html. [FN12] . Greg Bluestein and Ariel Hart, Kemp to seek Medicaid Obamacare waivers for Georgia, Atlanta Journal-Constitution (February 7, 2019) at: https://www.ajc.com/news/state--regional-govt-- politics/kemp-seek-medicaid-obamacare-waivers-for-georgia/l38UvSCPn7dInxecBQACNO/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=69727267&_hsenc=p2ANqtz- _t3Nkxa7i-Bjr0F1mIIzpGwn76F3SwRsuA5WAuicjCQ01WSgnA-1ucI8jHwHm8Lkur5LqKP62gRodRtR0syJZkazj3p&_hsmi=69727267. [FN13] . Ariel Hart and Greg Bluestein, Georgia governor signs health care waiver bill into law, Atlanta Journal Constitution (March 27, 2019) at: https://www.ajc.com/news/state--regional-govt-- politics/georgia-governor-signs-health-care-waiver-bill-into-law/S19OvcyLsHnP2zJEZCk8JJ/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=71235960&_hsenc=p2ANqtz-97rra [FN14] . Ariel Hart, Georgia gets bad news on Medicaid waiver funding, The Atlanta Journal-Constitution (July 31, 2019) at: https:// www.ajc.com/news/state--regional-govt--politics/georgia-gets-bad-news-medicaid-waiver-funding/rcP80rp82dQtbqMxLmnaRI/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=75254657&_hsenc=p2ANqtz--0ZR JxJjszxOK9RkmRCTzMLX_M&_hsmi=75254657#. [FN15] . Greg Bluestein and Ariel Hart, Kemp's Medicaid plan could pave way for limited expansion in Georgia, The Atlanta Journal-Constitution (November 2, 2019) at: https://www.ajc.com/news/state--regional-govt-- politics/kemp-medicaid-plan-could-pave-way-for-limited-expansion-georgia/TXFxD7gp2F4jydEv8965WK/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=78913239&_hsenc=p2ANqtz-8lorU B2W7L1sivvsvqgRBAexjplN32XiDaVv91NW90Qz9-q6h7w7g27yY6FPO8_Sf825DoNeKiZFEM&_ hsmi=78913239#. [FN16] . Sudhin Thanawala and Ben Nadler, Georgia governor unveils Medicaid expansion plan with work requirement, PBS (November 4, 2019) at: https://www.pbs.org/newshour/health/georgia-governor-unveils-medicaid-expansion-plan-with-work-requirement? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=78975978&_hsenc=p2ANqtz-9WR hYfS84jLL7waaooGaH5urxJ4YH40pzBl70&_hsmi=78975978. [FN17] . Rebecca Boone, Republican introduces bill to restrict Medicaid expansion; hearing set for Wednesday, Idaho Statesman (March 18, 2019) at: https://www.idahostatesman.com/news/local/article228100024.html. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -23- [FN18] . Audrey Dutton, Idaho's Medicaid waiver plan hits a roadblock, as feds reject the first part, Idaho Statesman (August 29, 2019) at: https://magicvalley.com/news/local/govt-and-politics/idaho-s- medicaid-waiver-plan-hits-a-roadblock-as-feds/article_ecc69d27-5800-516e-831e-5e4823e78cd6.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=76276754&_hsenc=p2ANqtz-8b6E m1LnFkCPw-KPeWIQqNQd3BDFVTQZcoI3fNAVVU3z2PK-238BoNyK7dxAIa23-MAsYbIMAVGNRmE&_ hsmi=76276754. [FN19] . Misty Inglet, Idaho's Medicaid expansion saga continues after first-round of proposed restrictions are rejected, KTVB.com (September 2, 2019) at: https://www.ktvb.com/article/news/local/capitol-watch/idaho-medicaid-expansion/277-dbc2c6e6- e94e-40b7-9278-634f96767ff0. [FN20] . Barbara Rodriguez, Senate Republicans OK work requirements for some Medicaid patients, Des Moines Register (March 19, 2019) at: https://www.desmoinesregister.com/story/news/politics/2019/03/19/medicaid-iowa-senate-republicans-work-requirements-medicaid- patients-bills-health-care-state-waiver/3214629002/. [FN21] . Lauren Weber, How Political Maneuvering Derailed a Red State's Path to Medicaid Expansion, Kaiser Health News (September 6, 2019) at: https://khn.org/news/kansas-medicaid-expansion-conservative-political-playbook/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=76526099&_hsenc=p2ANqtz-8Sq2 [FN22] . Kentucky delays start time for some new Medicaid rules, WLKY (February 1, 2019) at: https:// www.msn.com/en-us/news/us/kentucky-delays-start-time-for-some-new-medicaid-rules/ar-BBT1Gzh? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=69515054&_hsenc=p2ANqtz--1SnB VWkcN9YNi4mJWgi2j6E&_hsmi=69515054#page=2. [FN23] . Deborah Yetter, Federal court to hear arguments in case over Matt Bevin's Medicaid work requirements, Courier Journal (October 9, 2019) at: https://www.courier-journal.com/story/news/politics/elections/ kentucky/2019/10/09/bevin-work-plan-medicaid-goes-before-federal-appeals-panel/2443160001/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=77906640&_hsenc=p2ANqtz--3IGiF kNp90L07ckx8Df3op63-NPH7XbjN4tjIJD_2jtZzGTaMMinC6Rlp1Q04nNKjYembN7JvRAK8LsM&_ hsmi=77906640. [FN24] . Jessie Hellmann, Beshear vows to rescind Kentucky's Medicaid work requirements after claiming victory in governor's race, The Hill (November 5, 2019) at: https://thehill.com/policy/healthcare/469173-beshear-vows-to-rescind-kentuckys-medicaid-work-requirements- during-first. [FN25] . Louisiana House seeking to cover more children in Medicaid, WAFB 9 (May 20, 2019) at: https://www.wafb.com/2019/05/20/louisiana-house-seeking-cover-more-children-medicaid/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=72882722&_hsenc=p2ANqtz-8dVo [FN26] . Alex Acquisto and Michael Shepherd, Mills signs order to expand Medicaid in Maine, Bangor Daily News (January 3, 2019) at: https://bangordailynews.com/2019/01/03/politics/mills-signs-order-to-expand-medicaid-in-maine/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=68745302&_hsenc=p2ANqtz-9JhQ [FN27] . Joe Lawlor, Maine Gov. Mills rejects work requirements LePage sought for Medicaid, Portland Press Herald (January 22, 2019) at: https://www.pressherald.com/2019/01/22/mills-rejects-work-requirements-lepage-sought-for-medicaid-beneficiaries/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=69228595&_hsenc=p2ANqtz-9LYM zDxxERRRs7uC6miFOvr4wyi90Rl4S288wgKWAx_rs6T29OMkXIE7zE5YA&_hsmi=69228595. [FN28] © 2020 Thomson Reuters. No claim to original U.S. Government Works. -24- . Todd Spangler, Feds approve Michigan's Medicaid work requirement, beginning in 2020, Detroit Free Press (December 21, 2018) at: https://www.freep.com/story/news/local/michigan/2018/12/21/work-requirements-approved-michigan-medicaid/2388961002/. [FN29] . David Eggert, Lawsuit Challenges Medicaid Work Requirements in Michigan, U.S. News & World Report (November 22, 2019) at: https://www.usnews.com/news/politics/articles/2019-11-22/lawsuit-challenges-medicaid-work-requirements-in-michigan? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=79862851&_hsenc=p2ANqtz-9EQd Krfk1xmsyZ_GyKu1E8zKy5X-Jf0L5eRcB8XmnHSeduuM_41CTsHxsQYbkiGqiLqSb8XOzc-ED- N1dhdMEZsq9vzVmYArHHK0Y&_hsmi=79862851. [FN30] . Nathaniel Weixel, Advocates launch petition to place Medicaid expansion on 2020 ballot in Missouri, The Hill (September 4, 2019) at: https://thehill.com/policy/healthcare/459972-advocates-launch-petition-to-place-medicaid-expansion-on-2020-ballot-in? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=76479226&_hsenc=p2ANqtz- _TXYd4_tPIdupy8o0AUMRzENE7V_8AHrpqOqQnhqV5VCtRu7BDp5XQ0mvasTcoeqr3ht-2mq03V5Rc&_ hsmi=76479226. [FN31] . Michael Ollove, Lone Medicaid Expansion Defeat Offers Lessons for Other States, PEW (December 17, 2018) at: https:// www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/12/17/lone-medicaid-expansion-defeat-offers-lessons-for-other- states. [FN32] . Corin Cates-Carney, Medicaid Expansion Bill Clears Legislature, Awaits Governor's Signature, Montana Public Radio (April 18, 2019) at: https://www.mtpr.org/post/medicaid-expansion-bill-clears-legislature-awaits-governors-signature. [FN33] . Corin Cates-Carney, Governor Signs Montana Medicaid Expansion Renewal Bill, Montana Public Radio (May 9, 2019) at: https:// www.mtpr.org/post/governor-signs-montana-medicaid-expansion-renewal-bill. [FN34] . Grant Schulte, Nebraska's Medicaid expansion could take another 18 months, AP (April 1, 2019) at: https:// apnews.com/9d2ef5d739c8493b89898dcbec33e208? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=71361910&_hsenc=p2ANqtz- _qzvbYvf3CXWQSKGJIWzANAOwS9mNjG7e0BgzP4r_UJ-54eKhmaZ4zmJ7ZoqrKYbIBVlUBhlarMa-4-6kHdH--9Y5dY_ZLc5YaUYyBXEaKFXcx8 [FN35] . Don Walton, Medicaid expansion lawsuit challenges state's implementation delay, Lincoln Journal Star (August 28, 2019) at: https://journalstar.com/news/state-and-regional/govt-and-politics/medicaid-expansion- lawsuit-challenges-state-s-implementation-delay/article_0792c76f-9bf7-5c97-8db1-e80af8a33860.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=76224480&_hsenc=p2ANqtz-85Ry D7OCtukxk&_hsmi=76224480. [FN36] . Jason Moon, New Medicaid Expansion Work Requirement Could Apply to as Many as 15,000 People, New Hampshire Public Radio (December 5, 2018) at: https://www.nhpr.org/post/new-medicaid-expansion-work-requirement-could-apply-many-15000-people? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=68111201&_hsenc=p2ANqtz-- IqkHDQlVIHSNM8mMEmuiUkMu8GtGlioTTLVmLJDL-Hb_4hAzG4w&_hsmi=68111201#stream/0. [FN37] . Holly Ramer, N.H. bipartisan panel objects Trump tweaks to Medicaid rules, Concord Monitor (December 20, 2018) at: https://www.concordmonitor.com/N-H-bipartisan-panel-objects-Trump-tweaks-to-Medicaid-rules-22302048? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=68548149&_hsenc=p2ANqtz--3HiY VyMsj7xg6lDLc&_hsmi=68548149. [FN38] . Todd Feathers, Senate advances bill that could eliminate Medicaid work requirement in NH, New Hampshire Union Leader (March 14, 2019) at: https://www.unionleader.com/news/politics/national/senate-advances-bill- that-could-eliminate-medicaid-work-requirement-in/article_54766250-0385-5f62-b1d2-7c2d10ff6ba4.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=70818320&_hsenc=p2ANqtz- © 2020 Thomson Reuters. No claim to original U.S. Government Works. -25- _td-zcoBWr0Q9Zid-QhGpQOVBDPLRPM7_ 71fbrxBeLdwK2t86tYQWfFmbINHPd5A_J5gmV1WUoigBMHy8F0JJg6Gj2Uf27Uq5lNsLOo2_ wZOP9g5g&_hsmi=70818320. [FN39] . Jason Moon, Senate Bill to Roll Back Parts of Medicaid Work Requirement Goes Before N.H. House, New Hampshire Public Radio (April 10, 2019) at: https://www.nhpr.org/post/senate-bill-roll-back-parts-medicaid-work-requirement-goes-nh-house? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=71666000&_hsenc=p2ANqtz-9TES [FN40] . Dave Solomon, Bill to ease work requirements for Medicaid clears House, New Hampshire Union Leader (June 5, 2019) at: https://www.unionleader.com/news/politics/state/bill-to-ease-work- requirement-for-medicaid-clears-house/article_30b895d7-5c71-5961-af02-b5a9c3796099.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=73421493&_hsenc=p2ANqtz-8fhAb sQ7P2lEkTjNDNdKvAfKUJ3pLtx1f1UDoh9-ldoO98qYorxh5APnB-Da4VlB2GTg&_hsmi=73421493. [FN41] . Todd Bookman, With 17,000 Facing Penalty, N.H. Delays Medicaid Work Requirement, NHPR (July 8, 2019) at: https://www.nhpr.org/post/17000-facing-penalty-nh-delays-medicaid-work-requirement? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=74458031&_hsenc=p2ANqtz-9Mcjh [FN42] . Holly Ramer, Judge blocks New Hampshire Medicaid work requirements, WMUR 9 (July 29, 2019) at: https://www.wmur.com/article/ judge-blocks-new-hampshire-medicaid-work-requirements/28545097. [FN43] . Jason Moon, N.H.'s Medicaid Work Requirement Goes Before Federal Judge, NHPR (July 23, 2019) at: https://www.nhpr.org/post/ nhs-medicaid-work-requirement-goes-federal-judge#stream/0. [FN44] . Ethan DeWitt, State to appeal Medicaid expansion work requirement ruling, Concord Monitor (July 31, 2019) at: https://www.concordmonitor.com/Work-requirement-ruling-shuts-down-program-for-foreseeable-future-27398376? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=75254657&_hsenc=p2ANqtz--0ZR JxJjszxOK9RkmRCTzMLX_ M&_hsmi=75254657. [FN45] . NC House speaker says Medicaid expansion bill to move again, AP (September 11, 2019) at: https:// apnews.com/01e9764c7c82411192c8685a91b65798. [FN46] . Kaitlin Schroeder, Ohio Medicaid work rules: 5 things to know, Dayton Daily News (March 18, 2019) at: https:// www.daytondailynews.com/news/local/ohio-medicaid-work-rules-things-know/ijXaHshei7TK2ehqGhfnrN/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=70909754&_hsenc=p2ANqtz-89Si1 CJCIke2COA7zQzLXtUmGpoueisdUFcVe5Zv_pVTVjP9gVYLFUtGRXcOrVwM_6Z3pfRjOlgxSgxZhZqVmMNvfHw- spjOr4gzvfOeyc&_hsmi=70909754. [FN47] . Laura Hancock, Planned Ohio Medicaid work requirements call for case workers to contact recipients before they're cut off, Cleveland.com (October 31, 2019) at: https://www.cleveland.com/open/2019/10/planned- ohio-medicaid-work-requirements-call-for-case-workers-to-contact-recipients-before-theyre-cut-off.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=78728809&_hsenc=p2ANqtz-8B- H_2yyyMUekhvjn5v-gQs9NesNJ1uNklMUml0s8c7P7z6pGGsHq_ wieJZdx_YX6BRYAinBET7h4ojwpLw8OQseN1I4Ogv8XPeAp_oNMlQPgE76g&_hsmi=78728809. [FN48] . New campaign seeks to put Medicaid expansion up for a vote, AP (June 13, 2019) at: https:// www.seattletimes.com/seattle-news/health/new-campaign-seeks-to-put-medicaid-expansion-up-for-a-vote/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=73688039&_hsenc=p2ANqtz-- IX0_f_R9q-16aJI8Oiol00vyAzvHIcw5oIqV5rwI8I6Dnwkx6f-dTDnKOzx8kPG6lVhQlom4hF1e1Wc&_hsmi=73688039. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -26- [FN49] . Oklahoma high court weighing challenge on Medicaid expansion, AP (June 18, 2019) at: https:// www.modernhealthcare.com/medicaid/oklahoma-high-court-weighing-challenge-medicaid-expansion? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=73830418&_hsenc=p2ANqtz-- MvlVg17mWZb0G2P7iKyyrkJFe1TxndPLIMna_gRGupt9qaFaC2k412tevdT8Mb6tX8IuAkZ85PkKb&_hsmi=73830418. [FN50] . Nathaniel Weixel, South Carolina seeks Trump admin permission for Medicaid work requirements, The Hill (June 10, 2019) at: https://thehill.com/policy/healthcare/447781-south-carolina-seeks-trump-admin-permission-for-medicaid-work-requirements? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=73557497&_hsenc=p2ANqtz-- BZo1GV5P7igdmOXCP41Xh0BS1GomGyrekS9V8p7g_208SviQF2wf5Vc&_hsmi=73557497. [FN51] . Anita Wadhwani, Report: 68,000 parents would lose TennCare if work requirements take effect, Tennessean (January 31, 2019) at: https://www.tennessean.com/story/news/2019/01/31/report-tenncare-work-requirements-force-out-68-000-tennessee/2730521002/. [FN52] . Benjamin Wood, Utah voters approved Medicaid expansion, but lawmakers may delay it or impose work requirements, The Salt Lake Tribune (January 10, 2019) at: https://www.sltrib.com/news/politics/2019/01/10/utah-voters-approved/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=69001425&_hsenc=p2ANqtz-9YXZ WTrQLG3J6Re5tLUlm1rxJKhV1as3oOPahfnpyRe9&_hsmi=69001425. [FN53] . Nathaniel Weixel, Utah gov defies voters, signs limited Medicaid expansion, The Hill (February 11, 2019) at: https://thehill.com/policy/healthcare/429521-utah-gov-defies-voters-signs-limited-medicaid-expansion? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=69817833&_hsenc=p2ANqtz-- WwKtDrFyGfBw3ZLsBuivqdJGxtI1ijzue0gBHwsP-K--uC7Y6MXFoVc4LBffA4_63jtJIb-UWuQ7s1iyD3BB-6j3oDZRjA1bYWyk_ kbOGZSGKs&_hsmi=69817833. [FN54] . Robert Pear, Trump Administration Approves Medicaid Work Requirements in Utah, The New York Times (March 29, 2019) at: https://www.nytimes.com/2019/03/29/us/politics/medicaid-trump-utah.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=71313833&_hsenc=p2ANqtz- _A6bpRHHkkziryf20p2s2Kk93xi9RJhtUmobu_c7MZ5ORX_1rXOHqZDFqsJIRdWU6F8SCpV4QNov4EbhOXXUA2f&_hsmi=71313833. [FN55] . Utah won't get enhanced funding for partial Medicaid boost, AP (July 27, 2019) at: https:// www.apnews.com/96aa7624cc9141499cd161f4c49594cb? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=75107296&_hsenc=p2ANqtz--- UVGZJN09l1q2z49i1kMH8vF6y8pvP5Z4CcYrdQKm-HDZsCHlD3ZcANup-5eH9lsN8_6kKxrlP422ejVPEPNW5ngpE&_hsmi=75107296. [FN56] . Northam: 182K enrolled in new health coverage, AP (December 19, 2018) at: https:// apnews.com/2fed557b73744c34969de9f1f6089b11? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=68508942&_hsenc=p2ANqtz- _UJMRsiTGJuRFP_HV2sLf3iNlYmsXLQus2gNJOhIHgrbhrUXMZBS8G4_sy4yakFpqrrd6BwavmCHE440zHoa4- nU4EiY&_hsmi=68508942. [FN57] . 300,000 Virginians newly covered through Medicaid expansion, AP (August 1, 2019) at: https:// wtop.com/virginia/2019/08/300000-virginians-newly-covered-through-medicaid-expansion/? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=75296934&_hsenc=p2ANqtz--9RS [FN58] . Jessie Opoien, Senate GOP leader not ruling out accepting federal Medicaid expansion, The Cap Times (December 20, 2018) at: https://madison.com/ct/news/local/govt-and-politics/election-matters/senate-gop-leader- not-ruling-out-accepting-federal-medicaid-expansion/article_fc065cb0-1c00-51aa-8d76-bca8422c3ec3.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=68548149&_hsenc=p2ANqtz-- © 2020 Thomson Reuters. No claim to original U.S. Government Works. -27- 3HiYZDjtzUuoFgUP55sew8fHVF631l6pP2FGNtpm_0VGoGgIVHrH_ eo8jIkW3ZUAavuZkv5Owgt42uGSpeyolNf81aAKs_jHhD- VyMsj7xg6lDLc&_hsmi=68548149. [FN59] . John Bowden, Wyoming moves closer to Medicaid work requirement, The Hill (February 23, 2019) at: https://thehill.com/homenews/state-watch/431258-wyoming-moves-closer-to-medicaid-work-requirement? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=70211414&_hsenc=p2ANqtz-- mVLfxtI2eccIBLSp01BKqJraMpJhZbldZco5prX- yH-2B4_kBg8JVF9Q4UNIDjMd_lUaTq0Z84aD9KNBmXJIGYBqu2jRsQGg1lPFisRR1&_ hsmi=70211414. [FN60] . AP, Wyoming committee advances Medicaid expansion bill, KOTATV.com (November 13, 2019) at: https:// www.kotatv.com/content/news/Wyoming-committee-advances-Medicaid-expansion-bill-564872082.html? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=79406131&_hsenc=p2ANqtz- _t7MIHPSY_Ap8Rp8sqPiPEzIcM93PuBhsTtVAl3nVKMSuQjvri-bKrTyufyfgzHxvbJMU2_CHHHF2zw8yTW_ Why5AKnARatobMMfqZ9S4&_hsmi=79406131. [FN61] . Died sine die adjournment. [FN62] . Died sine die adjournment. [FN63] . Died in committee. [FN64] . Died in committee. [FN65] . Died in committee. [FN66] . Died in committee. [FN67] . Died in committee. [FN68] . Harris Meyer, Tennessee will test CMS' willingness to block-grant Medicaid, Modern Healthcare (May 7, 2019) at: https://www.modernhealthcare.com/payment/tennessee-will-test-cms-willingness-block-grant-medicaid? utm_campaign=KHN#D#aily#ealthP#olicyR#eport&utm_source=hs_email&utm_medium=email&utm_content=72470666&_hsenc=p2ANqtz- _yaYDjtZagb7LKKw371J1QVf8z11lha4ZOfkpsrMN&_hsmi=72470666. [FN69] . Died in committee. [FN70] . Died in committee. [FN71] . Postponed indefinitely. [FN72] . Left pending in committee. [FN73] . Left pending in committee. © 2020 Thomson Reuters. No claim to original U.S. Government Works. -28- [FN74] . Compiled from Centers for Medicare and Medicaid Services at: http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/. Produced by Thomson Reuters Accelus Regulatory Intelligence 05-Feb-2020 © 2020 Thomson Reuters. No claim to original U.S. Government Works. -29-