THE HENRY J. WW NAMD — Medicaid Directors FOUNDATION REPORT Medicaid Reforms to Expand Coverage, Control Costs and Improve Care: October 2015 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 Prepared by: Vernon K. Smith, Ph.D., Kathleen Gifford and Eileen Ellis Health Management Associates and Robin Rudowitz, Laura Snyder and Elizabeth Hinton Kaiser Family Foundation Acknowledgements We thank the Medicaid directors and Medicaid staff in all 50 states and the District of Columbia who completed the survey on which this study is based. Especially in this time of limited resources and challenging workloads, we truly appreciate the time and effort provided by these public servants to complete the survey, to participate in structured interviews and to respond to our follow-up questions. It is their work that made this report possible. We offer special thanks to three of our colleagues at Health Management Associates. Dennis Roberts developed and managed the database, and his work is invaluable to us. Barbara Edwards and Jenna Walls assisted with writing the case studies and we thank them for their excellent work. Table of Contents Executive SUMMMALY...........c:ccccssscessstecssseessssnecesseceesnsceesnscecssnseessnseessneteusnsessaaeeesuseecscaeeeesnaceesneceessneeessnseessnersseneeenencers 1 IMtrOductiOn............scccccsssscsscesssscccccesssnscccsssnccecssssnccecsessssnecessssscesessesncesecessueescessssneseeeseseeecesessneeeessssnceseessnnsecesssneeees 4 Eligibility, Enrollment, Premiums and Cost-Sharing.............ccsscccssssccssssccesssecessecesssscesssesesesesesssnesessnsesessnecensnesesees 5 Changes to Eligibility Standards ............. sc cesscssssessecesesecesessseseseceseeseoesssseseseeseseseneaseseseseseseseseneasesosessnenonenesonses 5 Enrollment Policies and Changes ............:ccsscssssssssssecesesesesecssssssssseceseseseesseasecesesesessseesssaseseseseneseseseesenenssenssenesenees 8 Premiums and Cost-Sharing ............:cscssssscsssccsssessssssssccesccsssesssssscssscecesseasseeneseacecseasssessseneasseassesecesseessesssseeeeaes 8 Table 2: Changes to Eligibility Standards in all 50 States and DC, FY 2015 and 2016..............cscsssssssssseseeeeeees 11 Table 3: Eligibility Changes in all 50 States and DC, FY 2015 and FY 2016.............cessssscssssssssssceseceeserseeneences 12 Table 4: Premium and Copayment Actions Taken in all 50 States and DC, FY 2015 and 2016..............cessceees 16 Managed Care Reforms ............sccscsssssssesesssessccssesssesscesecesscescesscescesacessececeescesesassaceceesasessesssasscesaeeaeseesesesessseeesaeaes 19 Populations Covered by Managed Care ..............:ccsscsssssessssecnsesssesssccesseesacsesnsessseenscsescecesesesnsecscessasersaesesaseneneesss 20 Benefits Covered Under Managed Care Contracts...........:cccsssccsssssssssccessccesssceessecessseseesseseessnceescncesessnesesseenesens 23 Managed Care Quality Imitiatives..............:cccssccssssccssseccsssccsssscessssccesssccessescsesececesaesessanecessnecesseecesneeesseeensseeensns 26 Medicaid Managed Care Administrative Policies .............::cssssccssssccssssccssssecsssseeessecensseseseseecessneesssanerenscerensnecens 26 Table 5: Share of the Medicaid Population Covered Under Different Delivery Systems, as of July 2015........ 29 Table 6: Medicaid Managed Care Expansions to New Groups in all 50 States and DC, FY 2015 and 2016.... 30 Table 7: Coverage of Select Benefits Under Medicaid Managed Care Contracts, as of July 2015..........:cssee 31 Table 8: Medicaid Managed Care Quality Initiatives in all 50 States and DC, FY 2014 - 2016...........:cessesses 32 Table 9: Minimum Medical Loss Ratio Policies for Medicaid MCOs in all 50 States and DC, as of July 2015 33 Table 10: Auto-Enrollment Policies for Medicaid MCOs in all 50 States and DC, as of July 2015............0000 34 Emerging Delivery System and Payment Reforms...............:ccsscsssssssseesceesesesesecesscecaeeeseescesaceneaenecescesecesesenssaseeees 35 Table 11: Delivery System and Payment Reform Initiatives in Place in all 50 States and DC in FY 2014........ 40 Table 12: Delivery System and Payment Reform Actions Taken in all 50 States and DC, FY 2015 and 2016 ..41 Long-Term Services and Supports Reforms. ............cssccssscssscssscessscceseceseceesscesseessceseaecessesesssesecessneesaesessesesssenaeenses 42 Long-Term Services and Supports Options in the ACA...0.........scssssssessssssesssesccesesescesseesesesesesesecessssasoessenecenereas 43 Table 13: Long-Term Care Expansions in all 50 States and DC, FY 2015 and 2016 ............ccccsssssssesseesssecesseees 46 Table 14: State Adoption of ACA LTSS Options in all 50 States and DC, FY 2014 - 2016..........ccccsscssscsssresssees 47 Provider Rates, Taxes and Benefits ............sccscsssssscecssssececscscecscsscssececscacscscuccovsececscacucseuscssasacacscacersessvecsesssesssnserss 48 Provider Rates .........sssssesssssssccsssnsssvsovsneeescssccnescesvsneuesevsnseseseususnescesssueesessusnenesseseseuescesaneucessscresessssaarersceseeneeeesses 49 Provider Taxes and Fe6S...........ssccccssssssscsssssnsscscesssnesccssssscacssesnnesscssassescssusneeecscssaesesessnenesccescuescssssuesessossacscsossase 51 Table 15: Provider Rate Changes in all 50 States and DC, FY 2015.......:cssscsssscssscesecessscsssccesccssecesesesssessncessnees 53 Table 16: Provider Rate Changes in all 50 States and DC, FY 2016............cssssscssscssssescssscessceseesasesscsssessecseeeaes 54 Table 17: Provider Taxes in Place in the 50 States and DC, FY 2015 and 2016..........s:sccsscssscsssssessessseesseeeseeens 55 Benefits Changes ..........ssccsscccsscssstecenssssssesssesseessnecsnsssnetsceeesseeeosnecensesensesusesenessneessssesnsesnetesauessneesueesnerseatesereseee 56 Table 19: Benefit Changes in the 50 States and DC, FY 2015 and 2016 ............csccssscsssccsseceseccncecsscessnerssereneseees 57 Table 20: Benefit Actions Taken in all 50 States and DC, FY 2015 and 2016............cssscccssssssseresesscecessecesseeeees 58 Prescription Drug Utilization and Cost Control Initiatives 0.0.0.0... csssssceseseseseseeeesesesesesesesesenessesesesssessnenorens 63 Table 21: Pharmacy Cost Containment Actions Taken in all 50 States and DC, FY 2015 and 2016 ................ 66 Priorities for FY 2016 and Beyond Reported by Medicaid Directors .............ssccssccssscessscescssnccsssceesscsesecesecsssesees 67 Methods ..........cssscccsssccesseccesseccessecesssncecssneecesseeesssesesssecessceseeseseasseecssanecsssnscsessesessaeeesnsnecesseeesensecasnesessnseessnesesseeeess 69 Appendix: Survey Instrument ..............:cssssssssssessesecesccssscesssscesecssscssssescsscsasseeeasesesscesecsssacescesssscesseaseassessseseessenues 71 EMTS .........ccccccccccccccsccssssnsessscseseserscssssssssssssssssssssssssssscssssssssssssvevsvsvsvsvsvscscscscscsccesescesecscscscasenscccecceseveseseseseceserens 81 Executive Summary Medicaid plays a significant role in the U.S. health care system, now providing health insurance coverage to more than one in five Americans. The Medicaid program continues to evolve, responding to changes in the economy, the broader health system, state budgets and policy priorities, and in recent years, to requirements and opportunities in the Affordable Care Act (ACA). This report provides an in-depth examination of the changes taking place in Medicaid programs across the country. The findings in this report are drawn from the 15 annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors. This report highlights policy changes implemented in state Medicaid programs in FY 2015 and those planned for implementation in FY 2016 based on information provided by the nation’s state Medicaid directors. Policy changes and initiatives described in this report include those in eligibility and enrollment, managed care, delivery and payment system reforms, provider payment rates, and covered benefits (including prescription drug policies). The report also looks at the key issues and challenges now facing Medicaid programs. Eligibility and enrollment changes in the ACA are continuing to have major policy implications for states in FY 2015 and FY 2016. As of October 2015, 31 states (including DC) had adopted the ACA Medicaid expansion. This includes 26 states that implemented the expansion in FY 2014, three additional states in FY 2015 (New Hampshire, Pennsylvania and Indiana) and two additional states in FY 2016 (Alaska and Montana). Other eligibility changes adopted or planned for states in FY 2015 and FY 2016 were small and targeted to a limited number of beneficiaries. As a result of new coverage pathways, a number of states are eliminating coverage for beneficiaries with incomes above 138 percent of poverty, many of whom qualify for Marketplace subsidies, as well as eligibility pathways to more limited Medicaid coverage. A few states had received or were seeking waivers to implement changes to premiums that were primarily related to the ACA coverage expansions (Arkansas, Indiana, Iowa, Michigan and Montana). Under the ACA, all states were required to implement enrollment changes including new streamlined application, enrollment, and renewal processes for individuals. Many states adopted new eligibility and enrollment systems. A number of states were still working through challenges in processing renewals at the start of FY 2016. States remain focused on strategies and initiatives to improve the effectiveness and outcomes of care, and to slow the growth in the cost of care. As of July 2015, a total of 48 states used some form of managed care to serve the Medicaid population, including 39 states (including DC) that contracted with risk- based managed care organizations (MCOs) to serve their Medicaid enrollees. In 21 of these states, at least 75 percent of all Medicaid beneficiaries were enrolled in MCOs. In FYs 2015 and 2016, the trend toward increased use of MCOs continues, as five states (Florida, Indiana, Iowa, Louisiana and Rhode Island) end their primary care case management (PCCM) programs and transition populations to MCOs. Other states are moving more eligibility groups, geographic areas and benefits into MCOs. As more states rely on MCOs for acute physical health care, a growing number of states are focusing on integration of physical health, behavioral health and long-term services and supports (LTSS) under the umbrella of managed care as a priority policy direction. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 ] With greater utilization of MCOs has come greater focus on quality performance. For FY 2015, a total of 21 states implemented new or expanded quality initiatives and 19 states planned to do so in FY 2016. (ES 1) These include MCO report cards and greater reporting of quality metrics, pay for performance, capitation withholds, performance bonuses or penalties, and special quality initiatives and performance improvement projects. States are implementing and expanding alternative delivery system and payment models. Thirty-seven (37) states in either FY 2015 or FY 2016, including 27 states in FY 2015 and 28 states in FY 2016, reported adopting or expanding one or more initiatives that seek to control costs, reward quality and encourage integrated care. (ES 1) Initiatives include patient-centered medical homes (PCMHs), Health Homes, Accountable Care Organizations (ACOs) as well as other initiatives to coordinate physical and behavioral health care and better manage the care of persons with multiple chronic conditions. Nearly a quarter of states are implementing initiatives in FY 2015 or FY 2016 to coordinate care and financing for dually-eligible Medicare- Medicaid beneficiaries. A limited number of states are implementing episode of care and DSRIP initiatives. States are implementing policies designed to “re-balance” care to allow more individuals to live in their homes and in the community. Nearly every state (46 states in both FY 2015 and FY 2016) took steps to expand care in the home and community. The ACA included some LTSS-related options intended to promote LTSS rebalancing including the Community First Choice Option and the 1915(i) HCBS State Plan Option. Thirteen (13) states reported having one or both of these options in place in FY 2014; an additional six states implemented at least one of these options in FY 2015 and eight states planned to do so in FY 2016. Ei Medicaid programs continue to add and expand payment and delivery system reforms in FYs 2015 and 2016. MFY 2015 OFY 2016 46 46 27 28 21 19 7 i Managed Care Managed Care Quality Emerging Delivery HCBS Expansions Expansions to New Initiatives System Initiatives Groups NOTE: Managed Care Expansions to New Groups refers to expansions to new groups, new regions, Increasing the use of mandatory enrollment, and new RBMC programs. Other Delivery System Initiatives Include new or expanded Initiatives related to PCMH, Health Homes, ACOs, Episodes of Care, DSRIP and Initlatives focused on dual ellgible beneficiaries. SOURCE: KCMU survey of Medicald officials In 50 states and DC conducted by Health Management Associates, October 2015. Given the size of Medicaid in state budgets, there is always pressure to control costs; however, improvements in the economy have allowed states to adopt more increases in reimbursement rates and benefits compared to restrictions. Medicaid provider payment rates and benefits are often adjusted in response to changes in the economy, with restrictions in times of economic downturns and state budget shortfalls, and restorations or enhancements when the economy and state revenues improve. In FY 2015 and FY 2016, more states implemented or planned for rate increases compared to restrictions (47 and 45 states increasing compared to 35 and 38 states restricting rates in those years). In this survey, a number of states reported that they have or are adopting reimbursement policies to reduce potentially preventable hospital readmissions and early elective deliveries. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 2 All states (except Alaska) use at least one provider tax or fee to help finance Medicaid. Eighteen (18) states increased or planned to increase one or more provider taxes or fees in FYs 2015 and 2016. Seven (7) of the Medicaid expansion states (Arizona, California, Colorado, Indiana, Kentucky, Nevada and Ohio) reported plans to use increased provider taxes or fees to fund all or part of the costs of the ACA Medicaid expansion beginning in January 2017, when states must pay a small share of the costs of the expansion. A total of 24 states expanded or enhanced covered benefits in FY 2015, and 18 states planned expansions in FY 2016. The most common benefit enhancements reported were for behavioral health and substance abuse services, HCBS and dental services for adults. Far fewer states reported benefit restrictions. States have a renewed focus on controlling rising prescription drug costs. Since 2014, rising drug prices and increasing program costs have refocused state attention on pharmacy reimbursement and coverage policies. The majority of states identified high-cost and specialty drugs (e.g., hepatitis C antivirals among others) as a significant cost driver for state Medicaid programs as well as increased costs for generics among other factors. Over two-thirds of the states in FY 2015 and half in FY 2016 reported actions to refine and enhance their pharmacy programs in response to new and emerging specialty and high-cost drug therapies. Medicaid directors reported a number of key priorities in FY 2016 and beyond. Medicaid is a large and complex program that provides health coverage for an increasing share of the population in each state. As the program continues to evolve, the key priorities for most directors are around implementing the ACA coverage provisions, controlling costs, implementing an array of complex delivery system reforms, and standing up new systems to support program operations related to enrollment, claims processing and delivery system reforms. Tackling this magnitude of change is a significant challenge, particularly given that most state Medicaid programs are operating within constrained resources, both in terms of staff . j a j Medicaid directors reported many key priorities for FY and funding. Emerging priorities mentioned 2016 and beyond. by Medicaid directors include population health and social determinants of health. (ES WV, e ‘e "| (ers) 1 'e ey ‘al or i t " es 2) State Medicaid programs are looking for opportunities to leverage other resources and stakeholders (such as state public health Population agencies and other payers) to improve the on | Systems and Health and i i i Implementation | COst Contro Administration ede quality of care provided and ultimately affect cee of Healt health outcomes for the populations they serve. Pursuing these significant goals has caused Medicaid to evolve into a major player in transforming the overall health care system. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 3 Introduction This report provides an in-depth examination of the reforms, policy changes and initiatives taking place in state Medicaid programs across the country. The findings in this report are drawn from the 15" annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured (KCMU) and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors. This was the fifteenth annual survey, which has been conducted at the beginning of each state fiscal year from FY 2002 through FY 2016.' (Copies of previous reports are archived here.) The KCMU/HMA Medicaid survey on which this report is based was conducted from June through August 2015. Medicaid directors and staff provided data for this report in response to a written survey and a follow-up telephone interview. All 50 states and DC completed surveys and participated in telephone interview discussions between June and August 2015. The survey asked state officials to describe policy initiatives and changes that occurred in FY 2015 and those adopted for implementation for FY 2016 (which began for most states on July 1, 2015”). The survey does not attempt to catalog all Medicaid policies. Experience has shown that adopted policies are sometimes delayed or not implemented for reasons related to legal, fiscal, administrative, systems or political considerations, or due to delays in approval from CMS. Not included in the survey are policy changes under consideration where a definite decision on implementation has not yet been made. A copy of the survey instrument is located in the appendix of this report. Key findings of this survey, along with 50-state tables providing more detailed information, are described in the following sections of this report: e Eligibility, Enrollment, Premiums and Cost-Sharing e Managed Care Reforms Emerging Delivery System and Payment Reforms Long-Term Services and Supports Provider Rates, Taxes and Benefits Priorities for FY 2016 and Beyond Reported by Medicaid Directors Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 4 Eligibility, Enrollment, Premiums and Cost-Sharing Key Section Findings e As of October 2015, 31 states (including DC) had adopted the ACA Medicaid expansion. This includes 26 states that implemented the expansion in FY 2014, three additional states in FY 2015 (Indiana, New Hampshire and Pennsylvania) and two additional states in FY 2016 (Alaska and Montana). Other eligibility changes adopted or planned for states in FY 2015 and FY 2016 were small and targeted to a limited number of beneficiaries. e Asa result of new coverage pathways, some states are eliminating Medicaid coverage for beneficiaries with incomes above 138 percent FPL, many of whom qualify for Marketplace subsidies, as well as eligibility pathways to more limited Medicaid coverage. Given new requirements and systems for enrollment and renewal, a number of states reported challenges processing MAGI-based renewals. The majority of states reported that they have implemented Hospital Presumptive Eligibility (HPE). Few states identified changes to premium and cost-sharing policies. Among states making premium changes, the majority related to ACA coverage expansions (Arkansas, Indiana, Iowa, Michigan and Montana). Six states reported new copayment requirements in either FY 2015 or FY 2016 for ACA Medicaid expansion populations. Indiana also reported new copayments for some existing Medicaid groups. Tables 2, 3 and 4 at the end of this section include additional details on eligibility, premiums and cost-sharing policy changes in FYs 2015 and 2016. CHANGES TO ELIGIBILITY STANDARDS The ACA included a number of significant changes to Medicaid eligibility and enrollment policies. One of the most significant changes was to extend Medicaid coverage to nearly all non-elderly adults with incomes up to 138 percent of the federal poverty level (FPL) ($16,242 per year for an individual in 2015), ending the historic exclusion of adults without dependent children, or childless adults, from the program. However, the June 2012 Supreme Court ruling on the constitutionality of the ACA effectively made the Medicaid expansion optional for states. Regardless of whether states implement the Medicaid expansion, all states were required to implement a range of other changes to eligibility and enrollment under the ACA. These changes included transitioning to use of Modified Adjusted Gross Income (MAGI) to determine financial eligibility for children, pregnant women, parents and low-income adults; eliminating asset limits for these same groups; establishing a new minimum eligibility limit of 138 percent FPL for children in Medicaid, which resulted in the transition of older children from the Children’s Health Insurance Program (CHIP) to Medicaid in some states; and providing new streamlined application, enrollment, and renewal processes for individuals. In addition, Medicaid agencies must coordinate eligibility determination and enrollment processes with the new Marketplaces. Altogether, the eligibility changes in 2014 represent historic program changes. Most of these changes occurred in FY 2014. As a result, very few changes in eligibility standards occurred for FY 2015 and FY 2016. As of October 2015, 31 states (including DC) had adopted the Medicaid expansion. (Figure 1) In Utah, discussions continue about implementing the Medicaid expansion, and other states may re-visit the decision in the next legislative session. Most states that have adopted the ACA Medicaid expansion did so in FY 2014 (26 states). In FY 2015, three additional states adopted the ACA Medicaid expansion (Indiana, New Hampshire and Pennsylvania.) In FY 2016, two states to date have adopted the ACA Medicaid expansion; Alaska implemented in September 2015, and Montana plans to implement in January 2016 pending federal waiver approval. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 5 Other eligibility changes in FY 2015 and FY 2016 were limited and targeted to small numbers of beneficiaries. For FY 2015, a total of eleven states made changes that expanded Medicaid eligibility and for FY 2016, five states plan to implement Medicaid eligibility expansions. (Figure 2) Only one state in FY 2015 and three states in FY 2016 made or are planning eligibility restrictions that were likely to leave individuals without other coverage options. A number of states are making changes to existing Medicaid eligibility pathways due to the availability of new coverage options; these changes are not counted as restrictions or expansions in this report. Figure 1 Over half of states have adopted the ACA Medicaid expansion. [Bl Adopted (31 States including DC) | Adoption under Discussion (1 State) DD not Adopting At This Time (19 States}| NOTES: Based on KCMU analysis of state executive activity . **MT has passed legislation adopting the expansion; It requires federal walver approval. *AR, IA, IN, MI, PA and NH have approved Section 1115 walvers. Coverage under the PA walver went into effect 1/1/15, but It is itioni to a state plan wi idults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 1, 2015. bret: //kfF. form/: indi tivity d. ir dicaid-under-th ct Figure 2 States with Eligibility Expansions / Enhancements FY 2011- FY 2016 Wf Other Eligibility Expansions B ACA Medicaid Expansion Nueces. FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 Adopted FY 2016 SOURCE: KCMU survey of Medicald officials In 50 states and DC conducted by Health Management Associates, October 2011 - 2015. COVERAGE TRANSITIONS As reported last year, with more coverage options available across the income spectrum, some states made changes to existing Medicaid pathways. These changes are discussed below and are noted in Tables 2 and 3 as “(#)” meaning they are not counted as a positive or negative eligibility change. Medicaid expansion states reducing eligibility for adults over 138 percent FPL. Both Minnesota and New York previously covered adults with incomes above traditional Medicaid eligibility levels through Medicaid waiver programs but have transferred those groups to their Basic Health Plans, discussed below. In addition, Connecticut reported plans to reduce Medicaid parent eligibility levels to 150 percent FPL in FY 2016; many parents previously eligible at the higher levels should be eligible for Marketplace subsidies. Basic Health Plan New York and Minnesota both implemented a Basic Health Plan (BHP) in FY 2015. Under the BHP provisions of the ACA, a state receives 95 percent of what the federal government would have spent on premium and cost-sharing subsidies in the Marketplace for the eligible population. The state then provides coverage through a state-managed BHP. While the BHP is not part of Medicaid, it affected Medicaid in these states. e Minnesota previously provided Medicaid to adults with income up to 200 percent FPL under its MinnesotaCare waiver, many of whom were likely to be eligible for Marketplace subsidies. Minnesota moved non-elderly non-pregnant adults with income between 138 percent FPL and 200 percent FPL from MinnesotaCare to its BHP on January 1, 2015. In FY 2015, New York implemented the “Essential Plan,” which is a BHP. The option transitions a Medicaid waiver population? and certain immigrants (funded with state-only dollars) with income at or below 138 percent FPL to BHP. The program will also cover adults ineligible for Medicaid with income below 200 percent of FPL in January 2016. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 6 States reducing or eliminating optional and limited Medicaid eligibility pathways. With new coverage options available either through the Medicaid expansion or the Marketplace, states have new options about how they treat some existing eligibility pathways for more limited Medicaid coverage, such as pregnancy related coverage, family planning-only programs, some spend-down programs, and the Breast and Cervical Cancer Treatment (BCCT) program.’ Prior to the implementation of the major ACA coverage changes, it was not clear if states would eliminate or scale back some of these programs in response to the new coverage options. While most states reported no current plans to change such pathways, many states indicated that enrollment in these groups has declined as more individuals are eligible under the adult Medicaid expansion group. However, a few states did note eligibility changes. (Table 1) In these cases, states generally plan to not allow new enrollment through these pathways but will continue coverage for those already enrolled. Table 1: States Eliminating Coverage for Optional and Limited Medicaid Eligibility Pathways In Place in Program 2013 (Prior Eliminated or Plans to Eliminate to the ACA) Breast and Cervical Cancer Treatment 5] Arkansas and Maryland (FY 2014), Illinois (FY 2016) Medically Needy / Spend Down Adults 36 Hawaii and Illinois (FY 2014); Pennsylvania’ (FY 2015). Pregnant Women Coverage > 138% FPL 43 Louisiana? (FY 2014) Family Planning Waivers or State Plan 33 Arizona, Arkansas, Delaware, Louisiana’? and Michigan‘ (FY 2014); Illinois (FY 2015); Ohio and Pennsylvania> (FY 2016) Notes: ' Pennsylvania eliminated spend-down for the disabled only; it is reinstating this coverage in FY 2016. ? Louisiana reported that pregnant women with income above 133% FPL were eligible for coverage under CHIP. 3 Louisiana converted its family planning waiver to a SPA, but eligibility declined to 133% FPL. * Michigan closed its family planning waiver to new enrollment in April 2014. * Pennsylvania is converting its family planning wavier to a SPA but is no longer accepting new enrollment. OTHER ELIGIBILITY CHANGES Other eligibility changes were more targeted or limited. These changes are noted in Table 2, but a few include: e In FY 2016, Colorado is implementing the option to eliminate the five-year bar on Medicaid eligibility for lawfully-residing immigrant children. e In FY 2015, Montana increased the cap on enrollment in its Mental Health Services Plan (MHSP) waiver from 2,000 to 6,000 adults with serious mental illness (before the state adopted the Medicaid expansion). e Virginia implemented a Section 1115 waiver to provide limited benefits to some uninsured adults with serious mental illness as part of the Governor’s Action Plan in FY 2015. (State legislation later reduced eligibility for this waiver from 100 percent FPL to 60 percent FPL, effective July 1, 2015.) e A number of states made changes to increase eligibility for the aged, blind and individuals with disabilities including eliminating the asset test (Vermont in FY 2015)and increasing income and asset limits for working individuals with disabilities (Virginia, New Jersey, Florida and Michigan). Only one state in FY 2015 (Wisconsin) and three states in FY 2016 (Ohio, Tennessee and Virginia) made or plan to make eligibility restrictions that are likely to leave individuals without other coverage options. These are targeted restrictions that would affect small groups of beneficiaries. In addition, California mentioned plans in FY 2016 to extend coverage to all undocumented children. This is a state-funded initiative and not funded through Medicaid; therefore, it is not counted as a Medicaid policy change in this report. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 7 ENROLLMENT POLICIES AND CHANGES RENEWALS As of January 1, 2014, new streamlined renewal policies for Medicaid also went into effect under the ACA. However, many states were delayed in implementing new renewal procedures. Recognizing this delay, during 2014, CMS allowed states to suspend renewals for existing enrollees for specified periods of time in order to free up staff resources to process new applicants and continue to update eligibility systems to implement new streamlined renewal procedures based on MAGI rules. States were asked if, at the time of the survey, they were experiencing challenges processing MAGI-based renewals and to describe those challenges. A number of states reported that they were experiencing challenges processing MAGI-based renewals at the time of the survey. Most of the issues reported were related to new eligibility systems, high volume of renewals, challenges matching data, and issues with pre-populated renewal forms. Most of these challenges were seen as temporary issues, but were not yet fully resolved in some states at the start of FY 2016. HOSPITAL PRESUMPTIVE ELIGIBILITY (HPE) Starting in January 2014, the ACA allowed qualified hospitals to make Medicaid presumptive eligibility determinations. States were asked to describe the level of participation among hospitals in their states. Thirty- three (33) states reported that they have implemented HPE and have at least one hospital participating in the initiative; the remaining states noted that either they were still working to implement HPE or that no hospitals had signed up to participate at the time of the survey. PREMIUMS AND COST-SHARING In July 2013, CMS released final rules designed to streamline and simplify regulations around Medicaid premiums and cost-sharing, consolidate existing law and provide for individual market premium assistance. Under the new rules, CMS clarified that total Medicaid premiums and cost-sharing incurred by all individuals in a Medicaid household may not exceed an aggregate limit of five percent of the family’s income, applied on either a quarterly or monthly basis. To enforce this, the new rules also extended the requirement that states track aggregate premiums and cost-sharing and suspend such payments if the household reached the five percent cap.’ In this year’s survey, several states commented on the difficulty of implementing a process to track these limits. In some cases, this has resulted in delays or reversals of plans to increase beneficiary cost- sharing. PREMIUMS With certain exceptions, Medicaid generally is not allowed to charge premiums to Medicaid beneficiaries with incomes at or below 150 percent FPL, although in limited cases certain populations may be charged premiums (sometimes referred to as “buy-in” programs) including: working individuals with disabilities eligible under the Ticket to Work and Work Incentives Improvement Act (TWWIIA) and children with disabilities in families with incomes that otherwise exceed Medicaid limits eligible under the Family Opportunity Act (FOA). States are also permitted under certain circumstances to impose premiums on parents receiving Transitional Medical Assistance (TMA) coverage. Prior to the ACA Medicaid expansion, a number of states also received Section 1115 waiver authority to expand coverage to higher income groups who were not otherwise eligible for Medicaid and to subject them to a premium requirement. Under the ACA, a few states have received federal waivers to impose premiums on their Medicaid expansion populations. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 8 In this year’s survey, states identified very few changes to premiums. Six states reported premium changes, including some with multiple changes. Five states made or proposed changes related to ACA coverage expansions (Arkansas, Indiana, Iowa, Michigan and Montana) and are described following the next section. Two states (Michigan and Minnesota) increased premiums for working individuals with disabilities.® COPAYMENT REQUIREMENTS Most state Medicaid programs require beneficiary copayments, but to varying degrees. Six states reported new copayment requirements in either FY 2015 or FY 2016; each of these states reported new copayment requirements for their Medicaid expansion populations. Indiana reported new copayments in FY 2015 and FY 2016 aside from the new Medicaid expansion group. Only three states reported any other actual or planned copayment increases for either FY 2015 (one state) or FY 2016 (two states). Two states reported elimination of copayments in FY 2015 and three states reported reductions in copayments in either FY 2015 (two states) or FY 2016 (one state). Increases for the ACA Expansion Population. Two states in FY 2015 (Indiana and Iowa) and four states in FY 2016 (Arizona, Montana, New Hampshire and New Mexico) adopted new copayments for their expansion populations. Four of these states (Arizona, Indiana, Iowa and New Mexico) noted changes in copayments related to non-emergent use of the Emergency Department (ED) for the expansion group; all but one (Indiana) planned to increase such copayments under existing state plan authority (up to $8). Indiana received a waiver under Section 1916(f) to test the effects of higher copayments ($8 for the first use of the ED and then $25 for subsequent use) than otherwise allowed under federal law (Section 1115 waiver authority does not extend to Medicaid cost-sharing requirements).” Additionally, two states (New Hampshire and Michigan) reported plans to increase copayments for some expansion adults in FY 2016. Pharmacy. A few states reported changes to pharmacy copayments in either FY 2015 or FY 2016. The nature and direction of these changes varied based on policy goals. New Mexico added pharmacy copayments for its expansion population. New Hampshire increased pharmacy copayments for its Medicaid expansion population, but eliminated pharmacy copayments for adults with incomes below 100 percent FPL. Two states reported decreased pharmacy copayments — an across the board reduction for working individuals with disabilities in New Mexico and a reduction in copayments for high value drugs (such as those for diabetes or mental illness) in South Carolina. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 9 ACA Medicaid Expansion Premium Waivers Five states (Arkansas, Indiana, Iowa, Michigan and Montana) used or plan to use Section 1115 demonstration waiver authority to implement premium requirements for their expansion populations. (Pennsylvania also received waiver authority to implement premiums for this population beginning January 1, 2016, but Governor Wolf chose to transition its Medicaid expansion from a waiver to a state plan amendment by September 2015, without premiums.) Arkansas, Indiana, Iowa, Michigan and Montana all implemented or plan to implement changes to premiums for their expansion populations in FY 2015 or FY 2016. Arkansas, in February 2015, added monthly contributions of $10 to $15 depending on income as part of Health Care Independence Accounts (HIA) available to newly eligible adults with incomes between 100 and 138 percent FPL in lieu of paying cost-sharing obligations. If individuals do not pay the HIA amounts, they would be assessed copayments at the point of service. Indiana’s Medicaid expansion waiver, Healthy Indiana Plan 2.0, requires most newly eligible adults with incomes from o to 138 percent FPL to contribute to a Personal Wellness and Responsibility (POWER) Account. Contributions range from $1 per month for individuals with incomes from zero to five percent FPL to $27 per month for individuals with incomes between 100 and 138 percent FPL. Payment is required before Medicaid enrollment is effective. Individuals have 90 days from the date of their invoice to make the required contributions without penalty. Failure to make contributions to the POWER accounts would result in a more limited benefits package and point of service copayments for those with incomes below 100 percent FPL and would result in a six month "lockout" from Medicaid eligibility for those with incomes above 100 percent FPL. Under Iowa’s Medicaid expansion waiver, enrollees with incomes over 50 percent FPL are required to make a monthly premium contribution, beginning in the second year of coverage (January 2015 at the earliest), which could be waived if the beneficiary completes specified wellness activities. Beneficiaries can also receive a hardship exemption if they cannot pay the premiums. In Iowa, there are no copayment requirements except for non-emergency use of the emergency department, which were waived during the first year of enrollment. This copayment was adopted under a SPA, not a waiver. The Healthy Michigan Plan requires contributions equal to two percent of annual income for persons between 100 and 138 percent FPL after they have been in the health plan for six months. (This is equivalent to the premiums that this population would face if they were enrolled in the Marketplace if the state had not expanded Medicaid). Total cost- sharing, including copayments (determined based on the past six months of services use) cannot exceed five percent of annual household income and is paid through the use of a dedicated health account called the “MI Health Account.” Enrollees can reduce their annual cost-sharing by participating in healthy behavior activities which include completing an annual health risk assessment. The imposition of these contributions began in FY 2015.° Failure to pay premiums would not result in a loss of eligibility. Montana’s Medicaid expansion waiver request would impose a premium of two percent of income for the entire ACA expansion group (from 0 to 138 percent FPL) as of January 1, 2016. Montana proposes dis-enrolling beneficiaries from 100-138 percent FPL for failing to pay premiums and seeks waiver authority to lock-out these individuals until overdue premiums are paid, or there is an assessment from the Department of Revenue against income taxes. Additionally, the waiver mentions that participation in a wellness program could exempt a beneficiary from disenrollment, but details were not provided. While the state is not requesting waiver authority, the proposal would require copayments according to maximum state plan amounts and consistent with federal law for all newly eligible beneficiaries.° Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 10 TABLE 2: CHANGES TO ELIGIBILITY STANDARDS IN ALL 50 STATES AND DC, FY 2015 and 2016 Eligibility Standard Changes FY 2015 eS (-) (a) (+) (-) X - Medicaid Expansion STATES Alabama Alaska Arizona Arkansas California Colorado Xx Connecticut X Delaware DC Florida Xx Georgia Hawaii Idaho Illinois Xx Xx : X - Medicaid Indiana . Expansion lowa Kansas x Kentucky Louisiana Xx Xx Maine Maryland Massachusetts Michigan x Minnesota Xx Mississippi Missouri X - Medicaid Expansion Nebraska Xx Nevada Montana x X - Medicaid Expansion New Jersey xX New Mexico New York x North Carolina x North Dakota Ohio X X Oklahoma Oregon New Hampshire Pennsylvania A= ees xX xX Expansion Rhode Island South Carolina South Dakota Tennessee x Texas Utah Vermont Xx Virginia xX x Xx Washington West Virginia Wisconsin x Wyoming Totals 11 1 6 5 3 4 NOTES: Positive changes from the beneficiary’s perspective that were counted in this report are denoted with (+). Negative changes from the beneficiary’s perspective that were counted in this report are denoted with (-). Several states made reductions to Medicaid eligibility pathways in response to either the availability of coverage through the Marketplaces and/or through the Medicaid expansion; these changes were denoted as (#) since most affected beneficiaries will have access to coverage through an alternative pathway. SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2015. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 11 TABLE 3: ELIGIBILITY CHANGES IN ALL 50 STATES AND DC, FY 2015 AND FY 20161 Fiscal aihili Eligibility Changes State vee g y g Alabama 2015 2016 Alaska 2015 2016 Adults (+): Medicaid expansion on September 1, 2015. (Estimated first year enrollment of 20,000) Arizona 2015 2016 Arkansas 2015 2016 California 2015 2016 Colorado 2015 2016 Other (+): Implement the option to eliminate the 5-year bar on eligibility for lawfully residing immigrant children. (Estimated to affect 1,699 individuals) Connecticut 2015 2016 Adults (#): Reduction in income limits for parent/caretakers to 150% of FPL (with disregard, effectively 155%) (Estimated to affect 23,700 individuals, of whom 1,350 are not eligible for Transitional Medical Assistance and will lose Medicaid eligibility effective 9/1/2015) Delaware 2015 2016 District of 2015 Columbia 2016 Adults (nc): Section 1115 waiver expires 12/31/2015. Plan to transition adults with incomes above 138% FPL from a Medicaid waiver to Medicaid state plan. (Estimated to affect 7,000 or more individuals) Florida 2015 Elderly and Disabled (+): Increased the minimum monthly maintenance income allowance and excess standard for community spouses of institutionalized people. (The number of nursing home residents eligible for Medicaid is also affected by 2015 cost of living adjustments and increases in the average private pay nursing home used to set LTSS policy.) 2016 Georgia 2015 2016 Hawaii 2015 2016 Idaho 2015 2016 'Positive changes from the beneficiary’s perspective that were counted in this report are denoted with (+). Negative changes from the beneficiary’s perspective that were counted in this report are denoted with (-). Several states made reductions to Medicaid eligibility pathways in response to either the availability of coverage through the Marketplaces and/or through the Medicaid expansion; these changes were denoted as (#) since most affected beneficiaries will have access to coverage through an alternative pathway. Other changes to Medicaid eligibility that are not likely to affect beneficiaries but were reported by states are denoted with (nc). Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 12 Illinois 2015 Adults (#): Family planning waiver expired December 31, 2014. Adults (nc): The state’s previous 1115 waiver (Cook County Care) ended June 30, 2014; adults transitioned to the new Medicaid expansion adult group July 2014. 2016 Adults (#): Plan to eliminate Breast and Cervical Cancer Treatment Program, with the expectation that these individuals qualify under the ACA expansion. (current enrollment is about 1,200) Indiana 2015 Adults (+): Adult expansion under HIP 2.0. (Affects an estimated 357,000 individuals) 2016 lowa 2015 2016 Kansas 2015 Adults (+): Presumptive Eligibility for Pregnant Women. (Estimated fewer than 500) 2016 Kentucky 2015 2016 Louisiana 2015 Adults (#): Eliminated Family Planning waiver for those over 138% FPL. Those with income below 133% FPL will move from waiver to state plan. (8,700 individuals) Adults (+): Family Planning SPA includes more services and adds coverage for men. 2016 Maine 2015 2016 Maryland 2015 2016 Massachusetts 2015 2016 Michigan 2015 2016 Adults (+): Income and asset expansion for working disabled adults. Minnesota 2015 Adults (#): Eliminated MinnesotaCare coverage for those with incomes between 133% and 200% FPL. Change is neutral for enrollees because Minnesota implemented a Basic Health Plan for those with incomes between 133% and 200% FPL. 2016 Mississippi 2015 2016 Missouri 2015 2016 Montana 2015 Adults (+): Raised cap on 1115 Mental Health Services Plan (MHSP) waiver from 2,000 to 6,000 adults with SMI. 2016 Adults (+): Waiver request in process to implement ACA expansion, including request for 12 month continuous coverage. Nebraska 2015 2016 Other (+): Individuals age 19-21 who entered into a subsidized guardianship or adoption at age 16 or older. (13 individuals) Nevada 2015 2016 New 2015 Adults (+): Implemented the Medicaid expansion as of July 1, 2014. Coverage became Hampshire effective August 15, 2014. The expansion was originally implemented through existing managed care programs and transitioned to a waiver January 2016. (estimated 50,000 individuals) 2016 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 13 New Jersey 2015 Elderly and Disabled (+): New Jersey implemented the “Miller Trust” option. New applicants formerly eligible for the Medically Needy program will establish qualified income trust, resulting in an expanded benefit package (beyond just long-term care services). Individuals in the “Medically Needy Spend-Down Adults” group on November 30, 2014, were grandfathered into this program.” (209 additional enrollees) 2016 New Mexico 2015 2016 New York 2015 Adults (#): Transfer some Medicaid waiver coverage (parents with incomes from 138% FPL to 150% FPL that receive an additional premium wrap to purchase coverage in the Marketplace) to Essential Plan (New York's BHP). 2016 North Carolina 2015 Adults (+): Income and resource disregard of payments from the Eugenics Compensation Program. 2016 North Dakota 2015 2016 Ohio 2015 2016 Adults (#): Ending Family Planning coverage group as of 1/1/16. Other (-): Change in transitional Medicaid for families from 12 months of eligibility to six months of eligibility with possible coverage for two consecutive six-month reporting periods. (Affects estimated 50,000 individuals) Oklahoma 2015 2016 Oregon 2015 2016 Pennsylvania 2015 Adults (+): Implemented the Healthy PA Section 1115 waiver January 1, 2015, which increased Medicaid eligibility for adults up to 138% FPL. (605,180 individuals) State converted this to a SPA starting in FY 2015 with completion in FY 2016. Adults (#); Medically-Needy Spend-down disabled adult coverage was discontinued with the implementation of Healthy PA; however, it is scheduled for reinstatement in FY 2016. (Affects 3,346 individuals) 2016 Adults (nc): Family Planning waiver converted to a SPA. Review of family planning enrollees for possible eligibility for full health care. (90,000 individuals) Adults (#): Reinstatement of medically needy spend-down for disabled adults. (3,346 individuals) Adults (nc): Converted all individuals enrolled in Medicaid expansion under the Healthy PA 1115 waiver to the Health Choices Medicaid expansion state plan as of September Ist. Rhode Island 2015 2016 South Carolina 2015 2016 South Dakota 2015 2016 Tennessee 2015 2016 Elderly and Disabled (-): In FY 2016 (7/1/2015), will begin limiting new LTSS enrollment into a 1915(i)-like group (offered under 1115 authority) to those eligible for SSI only. People already enrolled in the group under institutional income standards will be grandfathered. (Affects estimated 915 individuals) Texas 2015 2016 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 14 Utah 2015 2016 Vermont 2015 Other (+): Submitted SPA to disregard asset tests for non-ABD medically needy. 2016 Virginia 2015 Adults (#): Restored income eligibility for Family Planning coverage to 200% FPL. (Limit had been cut to 100% FPL on 1/1/2014.) Elderly and Disabled (+): For Ticket to Work disabled population, three changes: 1. Increased allowable earnings to $75,000 per year; any increase in a participants SSDI payments, or as a result of a COLA increase not counted as income as long as deposited in WIN account. 2. Unemployment benefits received due to loss of employment through no fault of the individual's own disregarded as income during a six-month grace period as long as deposited in the WIN account. 3. Income from a spouse not deemed to an applicant or enrollee in the program. (Estimate of 50 individuals.) Adults (+): Implemented a Section 1115 waiver program to expand limited benefit coverage to uninsured adults with incomes up to 100% FPL with serious mental illness. 2016 Adults (-): Per state legislation, income eligibility for the Section 1115 waiver program that expanded limited benefit coverage to uninsured adults with serious mental illness was reduced from 100% FPL to 60% FPL. Washington 2015 2016 West Virginia 2015 2016 Wisconsin 2015 Elderly and Disabled (-): Treating promissory notes as an asset. (Estimate of 40 individuals) 2016 Wyoming 2015 2016 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 15 TABLE 4: PREMIUM AND COPAYMENT ACTIONS TAKEN IN ALL 50 STATES AND DC, FY 2015 AND 20162 State Fiscal Year Premium and Copayment Changes Alabama 2015 2016 Alaska 2015 2016 Arizona 2015 2016 Copays (New only for expansion group): Impose mandatory copays to federal statutory limits and an $8 copay for non-emergent use of the ER on expansion adults. (Upon CMS approval) Arkansas Premiums (New only for expansion group): Added monthly contributions as part of Health 2015 = Independence Accounts available to newly eligible adults with incomes between 100-138% FPL. Contributions to the HIAs are in lieu of point of service copayments. (February 2015) 2016 California 2015 2016 Colorado 2015 2016 Connecticut 2015 2016 Delaware 2015 2016 District of 2015 Columbia 2016 Florida 2015 2016 Georgia 2015 2016 Hawaii 2015 2016 Idaho 2015 2016 Illinois 2015 2016 Indiana Premiums (New only for expansion group): POWER Account Contributions under HIP 2.0 for all low-income parents/caretakers and the new adult group (0-138% FPL) on a sliding scale. Those that fail to pay premiums within a 60-day grace period with income at or below 100% FPL are moved to a more limited benefit package and those with income over 100% FPL will be dis-enrolled from coverage and barred from re-enrolling for 6 months. (Feb 2015) Premiums (New): Non-expansion parent/caretaker relatives and those receiving TMA have the 2015 option of paying premiums to get additional benefits and in lieu of copays for services. Copays (New): Testing graduated copays ($8 then $25) for non-emergency use of the ER for non-expansion parent/caretakers and newly eligible adults under § 1916(f) authority. Copays (New for expansion group): Beneficiaries with income at or below 100% FPL who fail to pay premiums will be required to make copays in state plan amounts. Copays (Elimination): Remove copays for ABD enrollees in managed care. (April 2015) 2016 Copays (New): Restore copays for ABD enrollees in managed care (Jan 2016) ? New premiums or copays as well as new requirements (i.e. making copays enforceable) are noted as (NEW). Increases in existing premiums or copays are noted as (Increased), while decreases are noted as (Decreased) and eliminations are noted as (Eliminated). Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 16 lowa Premiums (New only for expansion group): Under the lowa Health and Wellness Plan (IHWP), enrollees with incomes over 50 percent FPL are required to make a monthly premium contribution, beginning in the second year of coverage, which could be waived if they complete specified wellness activities. Premium amounts are $5 per month for those with incomes 2015 between 50% to 100% FPL and $10 per month for those with incomes over 100% FPL. Individuals can file a hardship exemption if they are not able to pay. Jan 2015) Copays (New only for expansion group): All enrollees in the expansion group are be subject to $8 copay for non-emergent use of the ED. lan 2015) 2016 Kansas 2015 2016 Kentucky 2015 2016 Louisiana 2015 2016 Maine 2015 2016 Maryland 2015 2016 Massachusetts 2015 2016 Michigan Premiums (New only for expansion group): Healthy Michigan Plan requires MI Health 2015 Account contributions equal to 2% of annual income for persons between 100% and 133% FPL after they have been in the health plan for 6 months. (Oct 2014) Premiums (Increase): Legislation expanding the income and asset levels for Freedom to Work Medicaid (TWIIAA) included a revised premium schedule. (Oct 2015) 2016 = Copays (Increase): Increase in prescription, hospital, and office visit copays for Healthy Michigan Plan enrollees with incomes above 100% FPL. (Unknown date due to systems issues and CMS approval requirements.) Minnesota 2015 Cost-Sharing (Neutral Effect): The family deductible for adults in Medicaid was decreased to $2.75 per month, retroactive to 1/1/2014. (MCOs can waive the deductible.) Premiums (Decreased): Minimum premium for Medical Assistance for Employed Persons with 2016 | Disabilities (MA-EPD) reduced. (Sep 2015) Copays (Decreased): Decreased copayment amounts for MA-EPD group. (Sep 2015) Mississippi 2015 2016 Missouri 2015 2016 Montana 2015 Premiums (New only for expansion group): Waiver request to impose premiums (2% of 2016 income) for the entire ACA expansion group. Copays (New only for expansion group): Individuals with incomes up to 138% FPL will be required to pay copayments up to the maximum allowable amount under federal law. Nebraska 2015 2016 Nevada 2015 2016 New Hampshire 2015 Copays (Eliminated): Eliminating pharmacy copays for adults under 100% FPL. July 2014) Copays (Increased): Pharmacy copays for the expansion group (those above 100% FPL) are 2016 being increased from $1/$4 (generic/brand) to $2/$8. (Jan 2016) Copays (New only for expansion group): Expansion group will be subject to copays on some medical services. Jan 2016) Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 17 New Jersey 2015 2016 New Mexico 2015 Copays (Decreased): Pharmacy copayment decreased from $5.00 to $4.00 for working disabled Individuals. (FY 2015) Copays (New only for expansion group): Copays for non-emergency use of the emergency 2016 department and for brand-name prescriptions when there is a less expensive generic equivalent medicine available. (FY 2016) New York 2015 2016 North Carolina 2015 2016 North Dakota 2015 2016 Ohio 2015 2016 Oklahoma 2015 Copays (Increased): Most SoonerCare copays increased. (July 2014) 2016 Oregon 2015 2016 Pennsylvania 2015 2016 Rhode Island 2015 2016 South Carolina 2015 Copays (Decrease): Exempting certain high value drugs (including maintenance and certain 2016 eal drugs) from copay requirements for all full benefit Medicaid beneficiaries. (July South Dakota 2015 2016 Tennessee 2015 2016 Texas 2015 2016 Utah 2015 2016 Vermont 2015 2016 Virginia 2015 2016 Washington 2015 2016 West Virginia 2015 2016 Wisconsin 2015 2016 Wyoming 2015 2016 Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 18 Managed Care Reforms Key Section Findings e As of July 2015, a total of 39 states (including DC) had contracts with comprehensive risk-based managed care organizations (MCOs). Among the 39 states with MCOs, 21 states reported that 75 percent or more of their beneficiaries were enrolled in MCOs as of July 1, 2015, including four of the five states with the largest total Medicaid enrollment across the country. In both FY 2015 and in FY 2016, states continued to take actions to increase enrollment in managed care. The most common strategy was to expand voluntary or mandatory enrollment to additional eligibility groups, particularly those eligible for long-term services and supports (LTSS). In addition, five states (Florida, Indiana, Iowa, Louisiana and Rhode Island) are terminating PCCM programs in either FY 2015 or FY 2016 and shifting those populations into risk- based managed care. Nearly all states elect to exclude or “carve-out” certain services from MCO contracts. These services may be delivered and financed through another contractual arrangement (e.g., through a limited benefit risk-based prepaid health plan or “PHP”) or in the FFS delivery system. Most MCO states carve-in prescription drugs while LTSS are more likely to be carved-out. More than half of MCO states carve-in dental services for children. Behavioral health services arrangements are more varied, with more states opting to carve-out all or some of these services. However, more states are moving to carve-in behavioral health as well as LTSS in FY 2015 and FY 2016. In FY 2015, a total of 21 states implemented new or expanded quality initiatives, and 19 states planned to do so in FY 2016. The most common new or expanded initiatives in FY 2015 and 2016 were the adoption or increase of managed care payment withholds. As of July 1, 2015, 19 of the 39 states that contracted with comprehensive risk-based MCOs specified a minimum MLR for all or some plans. State Medicaid minimum MLRs vary, but most are set at 85 percent. A few states noted that their minimum MLRs varied by type of plan or population. States’ auto-enrollment algorithms also vary, but usually take into consideration previous plan or provider relationships, geographic location of the beneficiary, and/or plan enrollments of other family members. In addition, states reported that algorithms were designed to balance enrollment among plans, take into account plan capacity, and reward higher-quality MCOs. Tables 5 through 10 include more detail on the populations covered under managed care (Table 5), expansions to new groups (Table 6), selected benefits included in managed care contracts (Table 7), managed care quality initiatives (Table 8), and MLR (Table 9) and auto-enrollment policies (Table 10). Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 19 Managed care is now the predominant delivery Figure 3 system for Medicaid in most states, as Medicaid Medicaid Managed Care Models in the States, 2015 programs increasingly have turned to managed care as a means to help ensure access, improve quality and achieve budget certainty. As of July ' ae uA 2015, all states (including DC) except three — Alaska, Connecticut and Wyoming-— had in place some form of managed care. Across the 48 states with some form of managed care, a total of 39 states (including DC) had contracts with As of July 1, 2015 comprehensive risk-based managed care “we BB ico ony (29 states including DC) HI a MCO and PCCM (10 states) . * . se PCCM only {9 states) organizations (MCOs); 19 states administered a Fy PCCM only (tesa sates Primary Care Case Management (PCCM) tot counted here as such Ch ese small CEM program aerating In LA county forthe with HIV. Wyomn’sPeMH program uses PCCM authority to make PMPM payment but is net counted here as such; WY does have a PHP, but no MCOs. program, a managed fee-for- service based SOURCE: KCMU survey of Medicald officials In 50 states and DC conducted by Health Management Associates, October 2015. system in which beneficiaries are enrolled with a primary care provider who are paid a small fee to provide case management services in addition to primary care. Of the 48 states that operate some form of managed care, a total of 10 states operate both MCOs and a PCCM program while 29 states (including DC) operate MCOs only and nine states operate PCCM programs only."' (Figure 3) Wyoming, one of the three states without managed care (i.e., without an MCO or PCCM model), does operate a limited-benefit risk-based prepaid health plan (PHP). In total, 18 states (including Wyoming) contracted with one or more PHPs to provide behavioral health, dental care, maternity care, non-emergency medical transportation, or other benefits. POPULATIONS COVERED BY MANAGED CARE The share of Medicaid beneficiaries enrolled in Figure 4 MCOs, PCCM programs or remaining in fee-for- MCO Managed Care Penetration Rates for Select Groups of Medicaid Beneficiaries as of July 1, 2015 service varies widely by state. However, the share of Medicaid beneficiaries enrolled in MCOs has Mexcluded 1<25% 25-49% 50-74% M75+% steadily increased as states have expanded their managed care programs to new regions and new populations and made MCO enrollment mandatory for additional eligibility groups. In this year’s survey, states were asked to indicate the approximate share of specific Medicaid 3 . zZ populations that were served by MCOs, PCCM All States Children Adults Elderly and ACA ° . 395 39 39 Disabled Ex lon Adul programs and fee-for-service (FFS) for their nares “ae “aes 29 states nestates acute care services. As shown in Table 5, among Totes that hed inplesonted the ACA Medicaid oxponton av of lly 2015, 26hed MeOs operas SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2015. the 39 states (including DC) with MCOs, 21 states reported that 75 percent or more of their Medicaid beneficiaries were enrolled in MCOs as of July 1, 2015, including four of the five states with the largest total Medicaid enrollment, accounting for 4 out of every 10 Medicaid beneficiaries across the country (California, New York, Texas and Florida). (Figure 4 and Table 5) Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 20 Children and adults (particularly those enrolled through the ACA Medicaid expansion) are much more likely to be enrolled in an MCO than elderly Medicaid beneficiaries or those with disabilities. Thirty-two (32) of the 39 MCO states covered 75 percent or more of children through MCOs. Twenty-one (21) of the 39 MCO states covered 75 percent or more of low-income adults (e.g., parents, pregnant women) through MCOs. The elderly and people with disabilities were the group least likely to be covered through managed care contracts, with only 15 of the 39 MCO states covering 75 percent or more such enrollees through MCOs. (Figure 4) With the exception of some states participating in the CMS Financial Alignment Demonstrations, most states were even less likely to include those dually eligible for Medicare and Medicaid through managed care contracts. Of the 29 states that were implementing the ACA Medicaid expansion on July 1, 2015, 26 were using MCOs to cover newly eligible adults. (The three expansion states without risk-based managed care were Arkansas, Connecticut and Vermont.) The large majority (23) of these 26 states covered more the 75 percent of beneficiaries in this group through managed care. The three states with less than 75 percent MCO penetration for this group were Colorado, Illinois and Iowa (which each operate PCCM programs as well as MCOs.) Ten (10) of the 19 states with PCCM programs also contract with MCOs. In most of these states, MCOs cover a larger share of beneficiaries than PCCM programs. However, Colorado, Iowa and North Dakota are exceptions: a majority of Colorado’s enrollees were in the PCCM program, which is the foundation of the state's Accountable Care Collaboratives, and approximately four in ten enrollees in both Iowa and North Dakota were enrolled in those states’ PCCM programs as of July 1, 2015. MANAGED CARE POPULATION CHANGES Figure 5 In both FY 2015 and in FY 2016, states continued aie Managed Care Population Expansions, FYs 2015 to take actions to increase enrollment in managed care, although fewer states reported Actions to Expand the number served in Managed Care MFY 2015 FY 2016 doing so than in last year’s survey — likely reflecting full or nearly full MCO saturation in a growing number of states. Of the 39 states (including DC) with MCOs, a total of 20 states indicated that they made specific policy changes in either FY 2015 (13 states) or FY 2016 (13 ‘ ‘ Geographic Add New Groups New Mandatory Any Managed Care states) to increase the number of enrollees in Expansions Enrollment Expansions MCOs 9 compar ed to 34 in last year’s survey; no NOTE: States with MCOs were asked to report if they were expanding their managed care contracts to new geographic regions, adding new groups, or requiring new groups to enroll mandatorily. Included in adding new groups are states that transitioned new states with MCOs took any action to restrict MCO cae aE, RONU canaey af Medien oifcals in a ee tse conte by Health Management Associates, Octeber 2015. enrollment. The most common strategy was to expand voluntary or mandatory enrollment to additional eligibility groups (9 states in FY 2015 and 8 states in FY 2016). The eligibility group most commonly added to MCOs was persons eligible for LTSS (New Jersey, New Mexico, New York, Texas, Virginia and Washington), followed by the newly eligible adult group in states adopting the ACA Medicaid expansion (Illinois, Indiana, Pennsylvania and West Virginia). In addition, five states (Florida, Indiana, Iowa, Louisiana and Rhode Island) are terminating their PCCM programs in either FY 2015 or FY 2016 and shifting those populations into risk-based managed care (discussed below). Four states (Florida, Illinois, Louisiana and New York) made enrollment mandatory for specific eligibility groups in FY 2015, and nine states (Illinois, Iowa, Louisiana, New Hampshire, New York, Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 21 Rhode Island, Utah, Virginia and Washington) are doing so in FY 2016. Expansions of MCO geographic service areas were reported in five states in FY 2015, and in four states for FY 2016. (Figure 5) In addition, California reported plans to enroll undocumented children into MCOs in FY 2015. This is predominantly a state-funded program and is therefore not counted as a Medicaid policy change in this report. Notable MCO Expansions Implemented or Planned Florida transitioned nearly all Medicaid enrollees into MCOs on a phased-in schedule that was completed in August 2014. At that time, Florida’s PCCM, dental PHP and behavioral health PHP programs ended. Indiana began enrolling aged, blind and disabled enrollees into the Hoosier Care Connect MCO program in April 2015 and ended the Care Select PCCM program on June 30, 2015. Iowa plans to implement statewide MCO coverage for almost all Medicaid enrollees on January 1, 2016 (pending federal waiver approval) and end its PCCM and behavioral health PHP programs. Louisiana discontinued its Bayou Health Shared Savings (enhanced PCCM) model on January 31, 2015 and transitioned enrollees to MCOs. Rhode Island reported plans to eliminate its PCCM program for adults with disabilities (Connect Care Choice) in FY 2016 and transition enrollees to MCOs. PRIMARY CARE CASE MANAGEMENT (PCCM) PROGRAMS CHANGES Of the 19 states with PCCM programs, six indicated they enacted policies to increase PCCM enrollment in FY 2015 or FY 2016. Four (Iowa, Massachusetts, Montana and Nevada) indicated that they would enroll new Medicaid expansion adults in their PCCM programs; Alabama expanded its Health Home program statewide in FY 2015; and Colorado reported increased PCCM enrollment of persons dually eligible for Medicare and Medicaid as part of its Financial Alignment Demonstration. In contrast, seven states (Florida, Illinois, Indiana, Iowa, Louisiana, Oklahoma, and Rhode Island) have taken actions to decrease enrollment in their PCCM programs. Five of these states (Florida, Indiana, Iowa, Louisiana and Rhode Island) have ended or plan to end their PCCM programs and will transition PCCM enrollees to risk- based managed care. In June 2014, Illinois began transitioning 1.5 million PCCM enrollees to new care coordination models (including both risk-based managed care and PCCM models) in five mandatory enrollment regions. In Oklahoma, effective July 2014, individuals with creditable primary coverage are no longer eligible for the SoonerCare Choice PCCM program. LIMITED-BENEFIT PREPAID HEALTH PLANS (PHP) CHANGES Of the 18 states with one or more limited-benefit prepaid health plans (PHPs), six indicated they enacted policies to increase PHP enrollment in FY 2015 or FY 2016. California is planning to move coverage of substance abuse services from FFS to a PHP arrangement in FY 2016."? Iowa reported that the benefit for its Medicaid expansion population includes a dental PHP program, and Pennsylvania reported that the Medicaid expansion would increase enrollment in its behavioral health PHP program. Michigan indicated that its dental PHP program was expanding to additional counties; Wisconsin noted that its LTSS PHP was expanding to additional counties; and Wyoming expanded a behavioral health PHP program for children statewide. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 22 Four states reported actions that decreased enrollment in their PHP programs. Iowa and Florida folded, or will fold, PHP arrangements into their MCO programs (dental and behavioral health PHPs in Florida and a behavioral health PHP program in Iowa). Colorado ended a physical health PHP and replaced it with an MCO arrangement, and Washington is allowing “Early Adopter” counties to convert behavioral health PHPs to fully integrated MCO contracts. BENEFITS COVERED UNDER MANAGED CARE CONTRACTS Although MCOs are at-risk financially for providing a comprehensive set of acute-care services, nearly all states elect to exclude or “carve-out” certain services from MCO contracts. These services may be delivered and financed through another contractual arrangement (e.g., through a limited benefit risk-based PHP) or in the FFS delivery system. In this year’s survey, states were asked to indicate the delivery system(s) used to provide the following benefits: prescription drugs, children’s dental services, adult dental services, outpatient and inpatient mental health services and substance abuse services. The data presented shows this information only for populations enrolled under an MCO contract. Nearly all states exclude some populations from MCOs. For example, North Dakota does not cover children through its managed care contracts so North Dakota is not included in the “Dental (Children)” data. Ten states that operate MCOs do not cover dental services for adults (or only cover emergency dental), so these states are excluded from the “Dental (Adults)” counts. Figure 6 There is significant variation in the services states cover ; : i through Medicaid managed care contracts. category (exceptions may exist, such as limited Carve-ins for states that have MCOs as of July 1, 2015 carve-outs for selected drugs). “Varies” refers to “Carved-in” refers to the inclusion in MCO contracts of virtually all services in a given @ Carved-In cases where the inclusion of benefits in MCO contracts may vary by population or region or the za . ri) contract may cover some but not all services A re) Varies . . ry (e.g., states that carve-in some behavioral health D Carved-Out services but carve-out specialized services for : . . . “ Pharmacy Dental Dental Outpatient Inpatient Substance persons with serious mental illness). “Carved- (Children) (Adults) mental mental abuse out” means th at th es ervi ces are ] ar g ely ex clu d e d 39 states 38 states 29 states 39 states 39 states 39 states from MCO contracts and are instead covered {eNO doesnot cover cre in ther managed care conte, so they wee excluded rom the deal eatgory nd 10 sates un der eith er a FFS or PHP m Oo del. (Figure 6) SOUR KOM carvty et Medical tenis SU ctseee ca DC conducted by Health Management Assoclates, October 2015. States were also asked to describe any carve-in or carve-out changes for specific benefits in FY 2015 or planned for FY 2016. The most commonly reported benefit change was to carve-in behavioral health services and LTSS. PHARMACY Most MCO siates (33 of 39 states) carve-in their pharmacy services for the populations covered by their MCO contracts. Some of these states have small carve-outs for certain drugs or drug classes (e.g., HIV/AIDS drugs, medications for hepatitis C, mental health drugs, etc.). Three states (Iowa, Missouri and Nebraska) carve-out pharmacy benefits entirely, delivering these benefits on a FFS basis. Additionally, Tennessee reported that all drugs — except for certain physician-administered drugs — are carved-out and delivered FFS through a contracted pharmacy benefit manager. Two states (Indiana and Wisconsin) reported that pharmacy benefits are carved-in under certain MCO programs but carved-out of others. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 23 A number of states have carved pharmacy benefits into their managed care contracts in recent years. In this year’s survey, four states added or reported plans to add pharmacy benefits to their managed care contracts (Delaware, Iowa, Indiana and New York). Delaware reported carving pharmacy benefits into their MCO contracts in FY 2015. Iowa plans to carve the pharmacy benefit into its MCO contracts as it terminates its PCCM program and shifts this population to MCOs in FY 2016. Indiana implemented a new MCO program for the aged, blind and disabled population in FY 2015 that included pharmacy benefits; it also carved-in pharmacy benefits for the Healthy Indiana Plan (the state’s expansion group). New York, which had already carved most pharmacy benefits into managed care contracts, plans to carve-in hemophilia factor products and injectable antipsychotic drugs in FY 2016. In contrast, only one state (Maryland) reported carving some pharmacy benefits out of managed care contracts in FY 2016 (substance use disorder drugs). DENTAL Children’s Dental. More than half of MCO states that cover children under their managed care contracts'* generally carve-in children's dental services (21 of 38 states). Fifteen (15) MCO states carve-out children's dental services. The majority of these states cover children's dental on a FFS basis, but two states (Louisiana and Rhode Island) carve-out these services to a PHP and two states (Michigan and Utah) use both PHP and FFS models, depending on geographic area. Two states (Indiana and Wisconsin) reported that children’s dental services are sometimes carved-in: Indiana’s coverage varies by MCO program and Wisconsin’s coverage varies by geographic region. Adult Dental. Twenty-nine (29) of the 39 MCO states reported that they cover adult dental benefits; the other ten do not cover adult dental or only provide coverage for emergency dental services.'* Just over half of the MCO states that cover adult dental generally carve-in this benefit (15 of 29 states). Another four (Indiana, Massachusetts, Michigan and Wisconsin) sometimes carve-in adult dental services; in Indiana, Massachusetts and Michigan, the dental carve-in varies by MCO program while the dental carve-in in Wisconsin varies by geographic region. Eight of the remaining ten MCO states with adult dental benefits carve these services out!® to FFS, while two states (Iowa for expansion adults and Louisiana) carve-out adult dental services to PHPs. Indiana reported carving dental services into managed care contracts for selected populations (children and adults) in FY 2015. BEHAVIORAL HEALTH States cover behavioral health services (mental health and substance abuse services) through a wide array of delivery arrangements. Sixteen (16) MCO states generally cover outpatient mental health services through their MCO contracts; a similar number cover inpatient mental health services (15 states) and substance abuse services (16 states) through their MCO contracts. Of the remaining states, a number contract with PHPs to provide carved-out specialty behavioral health services. Eight states reported planned changes for FY 2016: six states (Arizona, Iowa, Louisiana, New York, Washington and West Virginia) plan to carve inpatient and outpatient mental health services as well as substance abuse services into at least some of their MCO contracts. Arizona plans to carve-in these services for their dual-eligible beneficiaries under their acute care contracts; New York continues to phase in coverage of these services under managed care plans. Iowa and Louisiana plan to transition coverage from PHPs to their managed care contracts. Washington also reported plans to carve these services into managed care contracts in Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 24 regions that elect to be “Early Adopters” as part of their effort to establish common purchasing regions for managed behavioral health and physical health. (Those that do not will contract separately for physical and behavioral health.) In addition, Mississippi plans to carve inpatient mental health services into its managed care contracts as part of its larger effort to carve-in inpatient services generally. Maryland reported carving substance abuse services out of managed care contracts in FY 2015. LONG-TERM CARE SERVICES AND SUPPORTS (LTSS) In this survey, about half of the MCO states reported that institutional LTSS (17 states) and home and community-based services (HCBS) (18 states) were provided only under the FFS delivery system. However, the survey did not capture whether LTSS was carved out of the states’ MCO arrangements or whether, instead, persons receiving LTSS were entirely excluded from MCO arrangements for all of their care (primary, acute, and behavioral health services). Only a small number of states reported that most LTSS is provided by MCOs — five states for institutional LTSS (Arizona, Hawaii, Kansas, New Mexico and Tennessee) and four states for HCBS (Arizona, Kansas, New Jersey and Tennessee). In some of these states, however, persons with intellectual and developmental disabilities (IDD) are excluded from enrollment or IDD waiver services are carved-out. In addition, 17 other MCO states reported providing some HCBS and institutional LTSS through MCOs, often based on specific population characteristics and/or geographic region (for example, under a Financial Alignment Demonstration for dual eligible beneficiaries). A number of states also mentioned PACE programs,'® but this site-based form of managed care was not counted for purposes of this analysis. Ten states reported changes for FY 2015 or planned for FY 2016. In FY 2015, six states (California, Michigan, New Jersey, New York, South Carolina and Texas) implemented MCO arrangements for institutional LTSS and HCBS for at least some populations; many of these states noted this change was in reference to the launch of dual eligible demonstrations (Michigan, New York, South Carolina and Texas). California implemented MCO contracts including both HCBS and institutional care services in some counties in FY 2015. New Jersey carved HCBS (services and beneficiaries) into managed care contracts as well as institutional services for new nursing facility entrants (those already in nursing facilities will remain in FFS). Texas also carved institutional LTSS into its non-dual managed LTSS program. Additionally, Idaho added institutional as well as HCBS to its Medicare-Medicaid Coordinated Plan (MMCP) in FY 2015." In FY 2016, five states will implement new LTSS MCO arrangements. Rhode Island will implement its dual eligible demonstration; Iowa will include both HCBS and institutional LTSS into new MCO contracts (pending federal waiver approval), and New Hampshire will add HCBS to its MCO contracts. New York and New Mexico will add additional LTSS (services and beneficiaries) to their MCO contracts (assisted living services in New York, waiver services for the medically frail in New Mexico). Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 25 MANAGED CARE QUALITY INITIATIVES All states with MCO programs track one or more quality measures and require other health plan quality activities to improve health care outcomes and plan performance. In this year’s survey, states were asked whether certain quality strategies were in place in FY 2014, or newly added or expanded in FY 2015 or FY 2016. Thirty-three (33) of the 39 MCO states (including DC) had one or more of these quality strategies in place in FY 2014. A majority (23 states) publicly reported or required MCOs to publicly report quality metrics (e.g., a “report card”), and over one-third had pay-for-performance provisions, capitation withholds, and performance bonuses or penalties in place in FY 2014 as well. (Figure 7) Four states mentioned other types of quality initiatives in place in 2014 including a requirement for some or all plans to be NCQA-accredited (Massachusetts and Tennessee), a requirement for MCOs to implement provider and member incentive plans (Missouri) and other reviews of performance, quality and network adequacy (Nevada). In FY 2015, a total of 21 states implemented new or expanded quality initiatives and 19 states planned to do so in FY 2016. The most common initiative that was [ ‘gue? new or expanded in FY 2015 and 2016 was Select Medicaid Managed Care Quality Initiatives, managed care payment withholds tied to quality FYs 2014 - 2016 performance. (Figure 7) Three of these states in i New/Expanded in FY 2015 [I New/Expanded in FY 2016 FY 2015 (California, Texas and West Virginia) and two of these states in FY 2016 (DC and Iowa) added new withhold requirements. Withhold amounts ranged from 0.15 percent (Virginia) to 11 19 10 9 9 21 five percent (West Virginia and Minnesota). 44 Several states also reported expanding or adding Pay for Managed Care Public Performace Other Quality] Any of Select _ _ ’ Performance Payment Reporting of Bonus/Penalty Initiatives Quality new pay-for- performance requirements as well salacein withhold Quality Mecies Inet as performance bonus or penalties and initiatives | Fr2ou: 79stes —Bstates——28states—Gstates A states | 33 states to publicly rep ort quality metri cs NOTES: States with MCOs were asked to report select quality Initiatives elther in place In FY 2014, new or expanded In FYs 2015 or * 2016. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2015. A few states mentioned additional types of quality initiatives. Minnesota will require MCOs to participate in its ACO and value-based contracting initiatives in FY 2016, and Pennsylvania will require MCOs to participate in community-based care management programs in FY 2015 and plans to require MCOs to participate in physical health/behavioral health integration efforts in FY 2016. MEDICAID MANAGED CARE ADMINISTRATIVE POLICIES MINIMUM MEDICAL Loss RATIOS For an MCO, the proportion of total per member per month capitation payments that is spent on clinical services and for quality improvement is known as the Medical Loss Ratio (MLR). Thus, the MLR represents the share of dollars that MCOs spend on providing and improving patient care, rather than on administrative costs, which include executive salaries, overhead, and marketing and profits. State insurance regulators commonly set a minimum MLR for commercial health plans, and the ACA mandates a minimum MLR for Medicare Advantage plans and for qualified health plans (QHPs) participating in the health insurance Marketplaces. There is currently no federal minimum MLR for Medicaid MCOs, nor are state Medicaid programs currently required to set minimum MLRs, but states are allowed to establish minimum MLR requirements for Medicaid health plans. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 26 As of July 1, 2015, 19 of the 39 states that contracted with comprehensive risk-based MCOs specified a minimum MLR for all or some plans, and 20 states did not have an MLR requirement. Seventeen (17) of the 19 states with a MLR requirement always applied it and two states applied it on a limited basis (e.g., for the new ACA Medicaid expansion population). State Medicaid MLRs vary, but are most commonly set at 85 percent. A few states noted that their minimum MLRs varied by type of plan or population. Other states that do not require a minimum MLR did note other mechanisms to monitor administrative costs and profits among Medicaid MCOs. Four states without minimum MLRs (Massachusetts, New York, Pennsylvania and Virginia) reported having a cap on profits and/or administrative costs. Two states (California and Utah) reported using a target MLR in their rate-setting process. One state (Texas) reported requiring “experience rebates” from plans with profits above a specified level, and one state (Kansas) reported not requiring a minimum MLR but does track MLRs of its plans. AUTO-ENROLLMENT Beneficiaries who are required to enroll in MCOs must be offered a choice of at least two plans. Those who do not select a plan are auto-enrolled in a plan by the state. Of the 39 states with comprehensive risk-based MCOs, all except one required some or all beneficiaries to enroll in an MCO. (The exception is North Dakota, which has only one health plan.) The proportion of beneficiaries who are auto-enrolled varies widely across states. Two states had auto-enrollment rates of 10 percent or less, while six states auto-enrolled over 75 percent of new MCO enrollees.'® States’ auto-enrollment algorithms also vary, but are usually designed to take into consideration previous plan or provider relationships, geographic location of the beneficiary, and/or plan enrollments of other family members. In addition, over half (23) of MCO states reported that their auto- enrollment algorithms were designed to balance enrollments among plans; 15 states considered plan capacity, and eight states took plan quality rankings into consideration. Other states noted plans to move toward including quality rankings in their auto-assignment algorithms in the future. Selected State Auto-Enrollment Quality Criteria Minnesota: Enrollees who do not select a plan are defaulted (i.e., auto-enrolled) into plans in their area with the highest overall quality score. Missouri: Auto-enrollment algorithm includes various factors including plan capacity, balancing enrollment among plans, certain performance criteria and consideration of the number of FQHCs, RHCs, CMHCs, and safety net hospitals in the plan. Washington: The auto-enrollment algorithm is based on an average of plan performance on two HEDIS measures as well as initial health screening rates. In May 2015, Washington’s Health Benefit Exchange implemented health plan selection online, enabling Medicaid beneficiaries to select a health plan online at the time of eligibility and recertification or at any time (as state does not currently have a “lock-in” policy). The state anticipates this change will reduce the number of auto-enrolled individuals. Using HEDIS measures for Plan Selection. In this year’s survey, states were asked if they used, or planned to use, HEDIS scores as criteria for selecting MCOs to contract with. Of the 39 states with MCOs, 14 answered “yes,” 22 answered “no,” and three states did not respond. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 27 Proposed Managed Care Rule On May 26, 2015, CMS released a long-awaited proposal to revise and modernize the Medicaid managed care regulations.'® The proposed rule addresses changes that have occurred in state Medicaid managed care and other programs since the regulations were last revised in 2002, including the emergence of managed long-term services and supports (MLTSS) and other innovative payment and delivery system models. Among other things, the sweeping changes proposed are intended to strengthen the quality of care provided to Medicaid beneficiaries, promote more effective use of data in overseeing managed care, strengthen actuarial soundness and other payment requirements, ensure beneficiary protections, promote beneficiary access to care and strengthen program integrity safeguards. The proposed rule is also intended to promote better alignment with other coverage including Marketplace Qualified Health Plans and Medicare Advantage plans.”° A variety of other stakeholders, including state Medicaid agencies, health plans, providers and beneficiary advocates, commented on the proposed rule, expressing support for select provisions and raising concerns over others.?! In its lengthy and detailed comment letter to CMS submitted on July 27, 2015, the National Association of Medicaid Directors (NAMD) identified both the specific concerns of its members as well as those provisions of the proposed rule viewed as positive policy approaches.” Three overarching concerns were identified: the new administrative costs that states would incur to implement the new requirements; the ability of CMS to carry out the new proposed oversight activities without resulting in problematic delays for states (e.g., approvals of capitation rates and contracts); and the apparent shift in the balance of regulatory authority for Medicaid managed care from the states to the federal government. Of particular concern is a requirement for states to provide a minimum 14-day period of FFS coverage before enrolling beneficiaries into managed care arrangements and the proposed capitation rate review process. In this survey, states were asked to identify the key issues, concerns or opportunities related to the proposed rule. A number of states indicated that the proposed rule was still under review and other states touched on many of the issues raised in the NAMD comment letter. The most frequently cited concerns related to the capitation rate review process and the 14 day FFS enrollment requirement. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 28 TABLE 5: SHARE OF THE MEDICIAID POPULATION COVERED UNDER DIFFERENT DELIVERY SYSTEMS, AS OF JULY 2015 Type(s) of Managed Care In Place Share of Medicaid Population in Different Managed Care Systems Oey) Oia Ales Alabama PCCM -- 64.3% 35.7% Alaska FFS -- -- 100.0% Arizona MCO 87.3% = 12.7% Arkansas PCCM* -- 57.6% 42.4%* California MCO and PCCM* 77.0% <1% 23.0% Colorado MCO and PCCM* 8.5% 64.9% 26.6% Connecticut FFS* -- -- 100.0% DC MCO 72.0% -- 28.0% Delaware MCO 90.0% -- 10.0% Florida MCO 79.0% -- 21.0% Georgia MCO 66.4% -- 33.6% Hawaii MCO 99.9% -- 0.1% Idaho PCCM* -- NR NR Illinois MCO and PCCM 52.7% 26.6% 20.7% Indiana MCO* 77.9% 0.6%* 21.5% lowa MCO and PCCM 12.0% 37.0% 51.0% Kansas MCO 95.0% -- 5.0% Kentucky MCO 91.0% -- 9.0% Louisiana MCO 71.0% ao 29.0% Maine PCCM -- NR NR Maryland MCO 82.0% -- 18.0% Massachusetts MCO and PCCM 51.5% 20.6% 27.9% Michigan MCO 77.0% == 23.0% Minnesota MCO 73.0% -- 27.0% Mississippi MCO* 67.0% -- 33.0% Missouri MCO 50.5% -- 49.5% Montana PCCM -- 73.7% 26.3% Nebraska MCO 74.0% -- 26.0% Nevada MCO and PCCM 68.0% 6.0% 26.0% New Hampshire MCO 89.8% -- 10.2% New Jersey MCO 93.0% -- 7.0% New Mexico MCO 87.5% -- 12.5% New York MCO 77.8% == 22.2% North Carolina PCCM -- NR NR North Dakota MCO and PCCM 21.0% 41.0% 37.0% Ohio MCO 78.3% -- 21.7% Oklahoma PCCM -- 69.9% 30.1% Oregon MCO* 93.0% -- 7 O% Pennsylvania MCO 70.0% -- 30.0% Rhode Island MCO and PCCM 87.7% 1.6% 10.7% South Carolina MCO 75.0% -- 25.0% South Dakota PCCM -- 86.0% 14.0% Tennessee MCO 100.0% ao =o Texas MCO 88.0% -- 12.0% Utah MCO* 62.8% -- 37.2% Vermont PCCM -- NR NR Virginia MCO 66.0% == 34.0% Washington MCO and PCCM 79.0% 1.0% 20.0% West Virginia MCO and PCCM 65.0% 2.0% 33.0% Wisconsin MCO 67.0% -- 33.0% Wyoming FFS* es == 100.0% NOTES: Share of Medicaid Population that is covered by different managed care systems. MCO refers to risk-based managed care; PCCM refers to Primary Care Case Management. Other/FFS refers to Medicaid beneficiaries that are not in MCOs or PCCM programs. *AR - included in “Other/FFS" include those receiving premium assistance through the Private Option (Medicaid Expansion). *CA - PCCM program operates in LA county for those with HIV. *CO - PCCM enrollees are part of the state's Accountable Care Collaboratives (ACO). *CT - terminated its MCO contracts in 2012 and now operates its program on a fee-for-service basis using four administrative services only entities. “ID - The Medicaid- Medicare Coordinated Plan (MMCP) has been recategorized by CMS as an MCO but is not counted here as such since it is secondary to Medicare. *IN - state ended its PCCM program as of July 1, 2015. *MS - risk-based managed care program does not cover inpatient hospital services. *OR - MCO enrollees include those enrolled in the state's Coordinated Care Organizations. *UT - MCO enrollees include those enrolled in the state's Accountable Care Organizations. *WY - the state does not operate a traditional PCCM or MCO program, but does use PCCM authority to make PCMH payments. SOURCE: Kaiser Commission on Medicaid and the Uninsured Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2015. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 29 TABLE 6: MEDICAID MANAGED CARE POPULATION EXPANSIONS IN ALL 50 STATES AND DC, FY 2015 AND 2016 States Geographic Expansions 2015 2016 Add New Groups 2015 2016 New Mandatory Enrollment 2015 2016 Any Managed Care Expansions 2015 2016 Either Year Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana lowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming X X X x< xx &* XK x< x < x< x< < «KK KOK OK Comments on Medicaid expenditures (Questions 1-3): Factors Driving Total Expenditure Changes. What were the most significant factors that affected growth or decline in total Medicaid spending (all funds) in FY 2015 and projected for FY 2016? Total Medicaid Spending FY 2015 FY 2016 (proj) a. Upward i. Most significant factor? Pressures ii. Other significant factors? b. Downward i. Most significant factor? Pressures ii. Other significant factors? Comments on Factors (Question 4): State GF/GR Spending: Are any of the factors identified below affecting GF/GR spending in FY 2015 or projected for FY 2016? Use the drop-down boxes to indicate whether the factors listed below are “Upward Pressures,” “Downward Pressures,” or “Not a Factor”. Use line “d” to identify other factors not listed in the table. Use line “e” to indicate if there is no significant difference in state GF/GR spending and total spending trends. Factors Affecting State General Fund Medicaid . Expenditure Growth Rate eS nO (fered a. Change in the regular FMAP b. Enhanced FMAP for Medicaid expansion c. Change in provider tax revenues or IGTs d. Other e. No significant difference in growth rates [| [| Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 Comments on State GF/GR Spending Factors (Question 5): 71 6. Medicaid Expansion Impact on Medicaid Spending and State Budgets: If your state has not implemented the ACA Medicaid expansion and does not plan to do so in FY 2016, please check this box [_| and skip to Section 2, Question 1. a. Compared to state projections for FY 2015, were PMPM costs for expansion enrollees higher, lower or on target with state projections? b. Please identify any sources of state budget savings or costs (in state-only dollars) attributable to the impact of Medicaid expansion outside of Medicaid that you are aware of for either FY 2015 or FY 2016 by using the drop- down boxes below (“Savings,” “Costs,” “No Significant Savings or Costs,” “Don’t Know,” or “N/A”.) Use the “Comments” section to briefly describe the savings or costs and to note challenges in attributing savings for a particular area (e.g. BH is a local responsibility, so savings do not accrue to the state budget.): State Budget Areas FY 2015 FY 2016 Comments Behavioral Health State Funding for Uncompensated Care Criminal Justice / Corrections iv. Increased Revenue (provider or general tax) Vv. Other: Comments on Expansion Impact (Question 6): SECTION 2: MEDICAID ENROLLMENT 1. Change in Total Enrollment: Please indicate (or estimate) the percentage changes in total Medicaid enrollment in FY 2015 and the projected change for FY 2016. (Exclude CHIP-funded Medicaid enrollees including “stair-step” kids). Percentage Change in Enrollment: 2015 over 2014 2016 over 2015 (proj.) Comments a. Total i. % ii. % iii. By Eligibility Group b. Children i. % ii. % iii. c. Pregnant Women i. % ii. % iii. d. Non-Elderly, Non-Disabled i. % ii. % iii. Non-Expansion Adults e. Expansion Adults i. % ii. % iii. f. Aged i. % ii. % iii. g. Disabled i. % ii. % iii. 2. Expansion Projections. Compared to FY 2015 projections, was enrollment for those newly eligible higher, lower or ontarget? Comments on Expansion Projections (Question 2): 3. Key Factors Driving Change in Enrollment: In the table below, please identify what you believe were the key factors that were upward and downward pressures on total enrollment in FY 2015, and expected to be in FY 2016. FY 2015 FY 2016 (proj.) a. Upward Pressures b. Downward Pressures Comments on Factors (Question 3): 4. Births Financed by Medicaid. a. How many births were financed by Medicaid in FY 2015? b. What share of all births in the state were financed by Medicaid in FY 2015? Comments on Births (Question 5): Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 72 SECTION 3: MEDICAID ELIGIBILITY STANDARDS, APPLICATION AND RENEWAL PROCESSES 1. Optional Eligibility Groups. Using the drop-down boxes, indicate whether the groups listed below were covered in FY 2013. If covered in FY 2013, indicate whether that coverage pathway was or will be eliminated (with the advent of the new Medicaid and Marketplace coverage options) by checking the appropriate box. If you select “Other Coverage Change,” please describe the change on the comment line below the table. For eliminations, please also provide an estimate of the number of people losing Medicaid eligibility (i.e., not eligible in another category). Covered in FY coverate a Nene conmage Est. Number of People Optional Medicaid Eligibility Group 2013 . Affected (e.g. # losing (Yes, No) 2014 2015 2016 Bes Change Medicaid ) (Check only one box per line) a. Breast & Cervical Cancer Treatment O O O O O Program b. Medically Needy Spend- Down Adults | [ | L] [] | J c. Pregnant Women over 133% FPL | [ | [| [_] [| [| d. Family Planning waiver | [_] L | [| [| [| e. Family Planning SPA | [ | [| LJ [J LJ Comments on optional eligibility groups (Question 1): 2. Other changes in Medicaid eligibility standards: Describe other changes in Medicaid eligibility standards* implemented in FY 2015 or adopted for FY 2016. (Exclude required changes, those listed in question 1, and changes in CHIP-funded program such as shifting stairstep children to Medicaid. Include changes related to the ACA Medicaid expansion.) Use the drop-down boxes to indicate the Year, the “Group Affected” (“Adults”, “ABD or Non-MAGI” or “Other’) and the “Nature of Impact” (“Expansion,” “Restriction,” or “Neutral” effect from the beneficiary’s perspective). If no changes, check the box on line “d.” Est. Number of Nature of Eligibility Change Year Group Affected People Affected Nature of Impact a|o/s|s . [_]No changes in either FY 2015 or FY 2016 *” Eligibility standards” include income standards, asset tests, retroactivity, continuous eligibility, treatment of asset transfers or income, enrollment caps or buy-in options (including Ticket to Work and Work Incentive Improvement Act or the DRA Family Opportunity Act.) Comments on change in eligibility standards (Question 2): 3. Hospital Presumptive Eligibility (HPE): Starting January 1, 2014, the ACA allows qualified hospitals to make Medicaid presumptive eligibility determinations if they choose to and agree to abide by state policies and procedures. Please briefly describe the level of participation by hospitals in your HPE program (e.g. approx. % of hospitals participating): 4. Corrections-Related Eligibility Processes. a. Has your state adopted a policy or does it plan to adopt a policy to suspend coverage or benefits (rather than terminating eligibility) when a Medicaid enrollee enters prison/jail? b. Please briefly describe other policies/initiatives intended to facilitate Medicaid enrollment for corrections- related populations. c. Please briefly describe other policies/initiatives intended to coordinate care for corrections-related populations enrolled in Medicaid. Comments on Corrections-Related Processes (Question 4). 5. Renewal: Are you experiencing challenges processing MAGI-based renewals? If yes, please describe. 6. FMAP Claiming for Medicaid Expansion States: As part of FMAP claiming, is your state experiencing any challenges in identifying low-income parents who would have been eligible prior to the Medicaid expansion? If yes, please describe. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 73 SECTION 4: PROVIDER PAYMENT RATES AND PROVIDER TAXES / ASSESSMENTS 1. Provider Payment Rates: Compared to the prior year, indicate by provider type any rate changes implemented in FY 2015 or planned for FY 2016. Use “+” to denote an increase, “-“ to denote a decrease, or “O” to denote “no change”. (Include COLA or inflationary changes as increases.) Note: the actual percentage change is helpful but a “4”, “.“ or “0” is sufficient. Provider Type FY 2015 FY 2016 Inpatient hospital Outpatient hospital Doctors — Primary Care N/A Doctors — specialists Dentists Managed Care Organizations Nursing Facilities Pharmacy Ingredient Cost Methodology mle |relo |olo [ola Pharmacy Dispensing Fees Comments on Provider Payment Rates (Question 1): ACA-Required Payment Increases for Primary Care. Did your state continue the ACA increase in whole or in part: a. After December 31, 2014 through the end of FY 2015? b. In FY 2016? Pharmacy Reimbursement: Briefly describe any change in ingredient cost reimbursement methodology (e.g., a change from/to AWP, WAC, AAC, NADAC, or other benchmark) and whether an increase or decrease in dispensing fees was associated with a change in ingredient cost methodology: Potentially Preventable Readmissions: Use the drop-down box to indicate if your state has or plans to implement an inpatient hospital reimbursement incentive/penalty for potentially preventable readmissions. Low-Income Pool (LIP). Does your state currently have a Low-Income Pool? a. Ifso, does your state plan to make any changes to its design? Please briefly describe such changes. Provider Reimbursement for Family-Planning and Pregnancy-Related Services. Do you use global fees to reimburse providers for family planning and perinatal services? (exclude reimbursement through RBMC) a. If yes, please indicate which services are reimbursed through these global fees (check all that apply): [_] Physicians for Vaginal delivery [_]| Physicians for Caesarian delivery [_] Certified Midwives [_] Physician for anesthesia [_] Prenatal visits [_] Prenatal screening tests [_] Post-Partum Visit [| Other: b. If not all the above listed services are covered under the global fee, how do you reimburse such services? (check all that apply): [_] Separate lump sum [_] Capitation [_] Fee-For-Service [_] Other: c. Has your state adopted or does it plan to adopt payment policies to remove incentives for conducting early elective deliveries? If yes, please briefly describe. Provider Taxes / Assessments: Please use the drop-down boxes in the table below to indicate provider taxes in place in FY 2014 and new taxes or changes for FY 2014 and FY 2015. In the far right columns, indicate whether caps of 3.5% or 5.5% of net patient revenues would require the state to decrease the established rate(s). Provider Group In place in FY Provider'Tax Changes (New, Increased, Decreased, Does tax exceed spectfied percentage of Subject to Tax 2014 (Yes, No) Eee TE eee TSA Net PatientRevenues ’ FY 2015 FY 2016 Exceeds 3.5% Exceeds 5.5% a. Hospitals b. ICF/ID c. Nursing Facilities d. Other: e. Other: f. Provider Taxes/Fees and the Medicaid expansion: Is your state using or planning to use provider taxes/fees to fund all or part of the costs of the ACA Medicaid expansion? Comments on provider taxes / assessments: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 74 SECTION 5: MONTHLY CONTRIBUTIONS / PREMIUMS AND OTHER COST-SHARING CHANGES 1. Changes in Monthly Contributions / Premiums: In the table below, please describe any monthly contribution or premium policy changes in FY 2015 or planned for FY 2016. (Exclude inflationary changes as well as requirements for CHIP-funded or premium assistance programs.) Use drop-down boxes to indicate Year and the Nature of Impact (“New,” “New only for expansion population,” “Increase,” “Decrease,” or “Elimination” of an existing requirement, or a “Neutral Effect.”) If there are no changes to report for either year, check the box on line “d.” Monthly Contribution Fiscal Year See Eligibility Groups Affected Nature of Impact een Action Date a. b. C. d. [_] No premium changes in either FY 2015 or FY 2016 2. Changes in Cost-Sharing: In the table below, please describe any cost-sharing policy changes in FY 2015 or planned for FY 2016. Use drop-down boxes to indicate Year and the Nature of Impact as you did in the question above. If there are no cost-sharing changes to report for either year, check the box on line “d.” Cost-Sharing Action Fiscal Year fee Sona Nature of Impact Waiver or SPA a. b. c d. [_] No cost-sharing changes in either FY 2015 or FY 2016 Comments on premiums and cost sharing (Questions 1 and 2): SECTION 6: BENEFIT AND PHARMACY CHANGES 1. Benefit Actions. Describe below any benefits changes implemented during FY 2015 or planned for FY 2016. (Include long term care benefit changes. Exclude pharmacy changes which are covered separately below.) Use drop-downs to indicate Year, Nature of Impact (from beneficiary's perspective, is it an “Expansion,” “Limitation,” an “Elimination,” or a change with a “Neutral Effect”). If there are no benefit changes for either year, check the box on line “d.” Benefit Change Year Effective Date Eligibility Groups Affected Nature of Impact Waiver or SPA b. c. d. C] No changes in either FY 2015 or FY 2016 Comments on benefit changes: Mental Health Parity. On April 6, 2015, CMS released a proposed rule that would apply certain provisions of the Mental Health Parity and Addiction Equity Act of 2008 to Medicaid and CHIP. Please briefly comment on the potential impact of the proposed rule on your program: HCBS State Plan Option (Section 1915(i)): States electing this option may offer the same range of HCBS as are available under Section 1915(c) waivers to individuals with incomes up to 300% of the SSI federal benefit rate. a. Did your state have a 1915(i) State Plan Amendment (SPA) in place in FY 2014? b. Please use the drop-down box to indicate whether a new 1915(i) SPA was “Implemented in FY 2015,” “To be implemented in FY 2016”, or whether the state has “No plans to implement.” c. Please briefly describe targeted populations/conditions: Has your state withdrawn a 1915(i) SPA in FY 2015 or plan to do so in FY 2016: Please briefly describe the 1915(i) SPA being withdrawn and why: Yes [_] No[_] Yes [_] No[_] Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 75 4. Community First Choice (CFC) Option (Section 1915(k)): States electing this option to provide Medicaid-funded HCBS attendant services and supports receive an FMAP increase of six percentage points for CFC services. Please use the drop-down box to indicate whether the CFC Option was “In place in FY 2014,” “Implemented in FY 2015,” “To be implemented in FY 2016”, or whether the state has “No plans to implement.” If your state withdrew or plans to withdraw a CFC Option SPA, please use the “Comment” line to indicate this and describe why. Comments on CFC Option: 5. Pharmacy Spending Trend. If available, please indicate below the annual percentage change in your state’s total Medicaid pharmacy expenditures, net of rebates, for FYs 2014, 2015 and projected for FY 2016. Total pharmacy expenditure growth rate 2014 over 2013 2015 over 2014 2016 over 2014 (proj.) i. % ii. % iii. % 6. Comments on Factors Affecting Pharmacy Spending Trend. What were the most significant factors that affected growth or decline in total Medicaid pharmacy spending in FY 2015 and projected for FY 2016? 7. Specialty/High-Cost Drugs (as your state defines/tracks them’) a. If available, please indicate for FYs 2014 and 2015 and projected for FY 2016 spending on specialty/high cost drugs as a percent of total drug spending. FY 2014 FY 2015 FY 2016 (proj.) Specialty Rx expenditures as a percent of total pharmacy expenditures: b. Please briefly describe any coverage policy or reimbursement changes targeted at specialty or high-cost drugs in FY 2015 or planned for FY 2016: c. Please describe any managed care-related policy changes targeted at specialty drugs in FY 2015 or planned for FY 2016 (*e.g., carve-outs, risk-sharing, uniform PA policy requirements, etc.): i. % ii. % iii. % 8. Selected Pharmacy Management Tools. For the pharmacy management tools listed below, indicate what was in place in FY 2014 as well as notable policy changes implemented in FY 2015 or planned for FY 2016. Check the box on line “d” if there are no changes to report for either year. Program Tool/Policy Mv oatar d FY(s) Specify Notable Policy Changes In Fiscal Year a. Preferred Drug List (PDL) LC] b. Supplemental Rebates L] c. Prescription Cap LC] d. [_] No changes in either FY 2015 or FY 2016 9. Other Pharmacy Changes. Please indicate any other significant pharmacy program changes implemented in FY 2015 or planned for FY 2016. Pharmacy Program Changes FY 2015 or FY 2016 a. b. Comments on pharmacy policy changes (Questions 5-9): * There is no standard definition of specialty drugs across Medicaid programs, but generally included are physician-administered drugs, biologics, Sovaldi and other new Hep C drugs, and other high-cost drugs. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 76 | SECTION 7: MEDICAID DELIVERY SYSTEM CHANGES Definitions: Throughout Section 7 and Section 7A, we use the following terminology: @ MCO: comprehensive risk-based managed care contracts e PHP: either a PIHP or PAHP, a benefit-specific risk-based prepaid health plan (e.g. behavioral health, dental, etc.) e FFS: refers to regular fee-for-service or a non-capitated managed care arrangement (e.g. PCCM) where providers are paid on a FFS basis by the state agency. 1. Medicaid Managed Care Overview. What types of managed care systems are in place in your state’s Medicaid program as of July 2015? (check all that apply): [_]Mco [_] PCCM (Primary Care Case Management) [_] PHP [_]| Other: [_] No managed care programs operating in your state Medicaid program as of July 2015. 2. Population. As of July 1, 2015, please indicate the approximate share of your Medicaid population served by each acute physical health care delivery system model listed in the table below. If possible, please also indicate the share of each eligibility group served by each health care delivery system model. Share of Medicaid population by Delivery System as of July 1, 2015 (Each column should sum to 100%) Delivery System Total Low-income | Expansion Aged & Population Child Adult Adult Disabled Duals a. MCOs % % % % % % . PCCM % % % % % % c. Fee For Service (FFS) % % % % % % Total 100% 100% 100% 100% 100% 100% Comments on populations served (Question 2): 3. Coverage of Select Benefits as of July 1, 2015. For each of the benefits listed in the table below, please indicate the delivery system(s) used to provide the benefit as of July 1, 2015 by checking the appropriate boxes. If the benefit is not covered for any eligibility group, please indicate that in the “Notes” column. Please note in the “Changes” column if you plan to change how these benefits are delivered (e.g. carve-in or carve-out) in FY 2016. For example: If prescription drugs for some populations are covered as part of capitation for comprehensive contracts with MCOs but paid fee-for-service for others, you would check the boxes in line a for MCO and FFS and briefly describe in the notes column how it differs by population. Delivery systems used Benefit as of July 1, 2015 (check all that apply): MCcO PHP FFS Changes in FY 2015 Changes in FY 2016 Notes (differs by population, region, etc.): h. Institutional LTSS a. Prescription drugs [| [| [| b. Dental — Kids [| [| [| c. Dental— Adults [| [| [| d. Outpatient mental health services U U U e. Inpatient mental health services U U U f. Substance abuse services U L U g. HCBS LTSS [_] [| [| L] LI | CJ Comments on selected benefit-related delivery system changes (Question 3): Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 SECTION 7A: MCOS / COMPREHENSIVE RISK-BASED MANAGED CARE 1. Did your state implement, or does it plan to implement, policy changes designed to increase the number of enrollees served in MCOs in FY 2015 or FY 2016? If “yes,” identify the types of policy changes that apply below: i. If so, which group(s) has been/will be shifted: RBMC Expansions FY 2015 FY 2016 a. Implement a new MCO program (no MCOs the previous year) [| [| b. Expand geographic service area [_] [_] c. Enroll additional eligibility groups in MCO plans [| [| i. If so, which group(s) has been/will be added: d. Change from voluntary to mandatory enrollment [| [| 2. If your state implemented, or plans to implement, policy changes designed to decrease the number of enrollees served in comprehensive managed care plans in FY 15 or FY 16, please briefly describe the changes: Comments on MCO enrollment changes: 3. Medical Loss Ratio (MLR). a. As of July 1, 2015, has your state established a minimum MLR requirement for Medicaid MCO plans? b. Ifo, what is the minimum MLR for Medicaid MCO plans? c. Are care management costs counted as medical expenses? Comments on MLR: 4. Auto-Enrollment: Does your state use an auto-enrollment process for those who don’t select a plan? a. If yes, about what share of enrollees was auto-assigned on an average monthly basis in FY 2015? % (if the percentage varies by program and/or geographic area, please explain in the comment line.) b. Please indicate whether the factors listed below are included in your state’s auto-enrollment algorithm. (Check all that apply.) i. (_] Plan capacity iv. [_] Plan cost ii. [_] Balancing enrollment among plans v. [_] Encouraging new plan entrants ii. [] Plan quality ranking iv. [_] Other measure (please specify) Comments on auto-enrollment process: 5. MCO Program Initiatives to Improve Quality of Care. While all states track specific quality measures (e.g., HEDIS©), we are interested in strategies to enhance quality in managed care contracts. In the table below, please indicate whether your state had any of the following initiatives in place in FY 2014, significantly expanded or added such initiatives in FY 2015 or plans to do so in FY 2016. capitation payments was withheld in FY 2015? A tesa In Place New or Expanded in: Quality Initiatives in MCO Contracts in FY 14 FY 15 FY 16 a. Pay for Performance L] L] L_] b. Managed Care Payment Withhold L| L] L] c. Require MCOs to publicly report quality metrics (e.g., a “report card”) L | L | L | d. Performance Bonus or penalties L | L_| L_] e. Other: L] L_] L| f. Other: LJ L] LJ g. 2015 Withhold. If you use a Managed Care Payment Withhold to drive quality improvement, what share of MCO h. 2016 Withhold. Please indicate any changes in the withhold requirement to be applied in FY 2016: i. HEDIS Measures in Contracting. Does your state include or plan to include HEDIS scores among the criteria for selecting plans to contract with? Comments on Quality Initiatives in MCO Contracts: 6. Proposed Managed Care Regulation. Please identify the key issues, concerns or opportunities for your state’s Medicaid program relate to the proposed rule. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 78 SECTION 7B: PRIMARY CARE CASE MANAGEMENT (PCCM) 1. Did your state implement, or does it plan to implement, policy changes designed to increase the number of enrollees served through your PCCM program in FY 2015 or FY 2016? a. If so, please briefly describe the change(s): Did your state implement, or plan to implement, policy changes designed to decrease the number of enrollees served through your PCCM program in FY 2015 or FY 2016? b. If so, please briefly describe the change(s): SECTION 7C: BENEFIT-SPECIFIC RISK-BASED PREPAID HEALTH PLAN (PHP) Did your state implement, or does it plan to implement a new PHP program or policy changes designed to increase the number of enrollees served through a PHP in FY 2015 or FY 2016? a. If so, please briefly describe the change(s): Did your state eliminate a PHP program or implement, or plan to implement, policy changes designed to decrease the number of enrollees served through your PHP program in FY 2015 or FY 2016? b. Ifso, please briefly describe the change(s): SECTION 7D: DELIVERY SYSTEM OR PAYMENT REFORMS Did your state implement or expand, or does it plan to implement or expand, delivery system or payment reform initiatives (including multi-payer initiatives) in FY 2015 or FY 2016? If “yes,” please check below all applicable initiatives implemented or expanded. Please use the “Notes/Additional Information” column to briefly describe or provide a web link where a description or additional information can be found for each initiative in place or new/expanded: . casas In Place in New or Expanded in: -_ . Delivery System Reform Initiatives FY 14 FY 15 FY 16 Notes/Additional Information: a. Patient-Centered Medical Home [_] [| [_] b. Health Homes (under ACA Section 2703) [ ] c. Accountable Care Organization [ ] [ ] [ | d. Dual Eligible Initiative (Financial Alignment Demonstrations) CL] LC] LC] e. Dual Eligible Initiative (Outside the Financial Alignment Demonstrations) CL] LC] LC] f. Episode of Care Payments [| [| [ ] g- Delivery System Reform Incentive Payment (DSRIP) waiver CL] LC] LC] h. All-Payer Claims Database [| [| [ ] i. Other: [| [| [ ] 2. If your state has or will implement an initiative with a focus on coordinating behavioral and physical health at the provider level, please briefly describe the initiative and your experience so far (issues or challenges, opportunities, etc.): 3. If your state has or will implement an initiative focused on population/community health or the social determinants of health, please briefly describe the initiative and your experience so far (issues or challenges, opportunities, etc.): 4. lf your state is involved in the development or implementation of a SIM grant, please briefly describe the implications of the SIM grant for your state’s Medicaid program: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 79 5. If your state has or will implement an initiative focused on reducing non-emergent use of the Emergency Department (ED), (e.g. super-utilizer programs) or other initiatives, please briefly describe the initiative and your experience so far (issues or challenges, opportunities or positive effects): SECTION 8: LONG TERM SERVICES AND SUPPORTS (LTSS) REBALANCING 1. Did your state increase, or does it plan to increase, the number of persons receiving LTSS in home and community based settings in FY 2015 or 2016? If “yes,” please check below all of the rebalancing tools/methods used: LTSS Rebalancing Tools/Methods FY 15 FY 16 a. Expand the number of persons served in home and community-based services (HCBS) waivers O O (including those funded through the Money Follows the Person program) b. Expand the number of persons served under the HCBS State Plan Option - 1915(i) | [| c. Build rebalancing incentives into managed care contracts covering LTSS | [| d. Add anew PACE site or increase the number of persons served at PACE sites | [| e. Close/down-size a state institution and transition residents into community settings [| [| f. Implement/ tighten Certificate of Need program or impose a moratorium on construction of new O O institutional beds g. Other: | [| Comments on Rebalancing Tools/Methods (Question 1): 2. If your state added new restrictions or limitations, or plans to do so (such as eliminating a PACE site or capping HCBS waiver enrollment), on access to HCBS in FY 2015 or FY 2016 (other than benefit changes described under Section 6 above), please briefly describe the changes: 3. If your state removed restrictions or limitations, or plans to do so, on institutional LTSS (e.g., lift or liberalize a Certificate of Need program or moratorium) in FY 2015 or 2016, please briefly describe the changes: 5. HCBS Settings Rule: Please briefly describe any significant issues, concerns or opportunities that have emerged to date related to the implementation of your state’s HCBS Statewide Transition Plan required by the HCBS Final Rule (released in January 2014.) Other LTSS Comments: | SECTION 9: FUTURE OUTLOOK FOR THE MEDICAID PROGRAM AND ACCOMPLISHMENTS / SUCCESSES TO DATE 1. What do you foresee as the top two or three issues or challenges over the next year or so for your state’s Medicaid program? 2. What do you foresee as the two or three top priorities for your state’s Medicaid program over the next year or so? 3. Does the Supreme Court’s decision in King v. Burwell have implications for your state’s Medicaid program? Please briefly describe. 4. When you step back and look at your Medicaid program - considering things such as administration, its impact in the community and health care marketplace, what you have accomplished and what you are accomplishing - what is it that you take the most pride in about Medicaid in your state? This completes the survey. Thank you very much. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 80 Endnotes ' An archive of previous survey reports is available at: “50-State Medicaid Budget Survey Archives,” Kaiser Commission on Medicaid and the Uninsured, accessed October 1, 2015, http://kff.org/medicaid/report/medicaid-budget-survey-archives/. ? State fiscal years begin on July 1 except for these states: NY on April 1; TX on September 1; AL, MI and DC on October 1. 3 New York transitioned parents with incomes between 138 percent FPL to 150 percent FPL who received an additional Medicaid- funded premium wrap to purchase coverage in the Marketplace to the BHP. * Family planning waivers and SPAs offer limited benefits while the breast and cervical cancer treatment program and the medically needy spend-down programs offer full Medicaid benefits but are limited to those with either a specific condition or after meeting spend- down requirements. Medicaid for Pregnant Women varies in scope of services. Some states only cover services very directly related to the pregnancy while other states deem that any health care issue could possibly affect a pregnancy. > Previously this requirement had applied to states that applied alternative cost-sharing arrangements under 42 U.S.C. § 13960-1. David Machledt and Jane Perkins, Medicaid Premiums and Cost Sharing (Washington, ve: National Health Law Program, March 25, 2014), http: lVhBe. 6 Since the survey was fielded, two states (AZ and MI) have submitted waiver requests that include premium and cost-sharing proposals. Each of these waiver proposals must be approved by CMS before the states could implement such changes. Additionally, state legislation in Ohio requires the state to seek a waiver to implement Health Savings Accounts (HSAs) for non-disabled adults in Ohio Medicaid. The state is still developing such a proposal; at the time of this report, no proposal had been publicly released. - Arizona released a waiver proposal in August 2015 based on state legislation calling for the establishment of HSAs with contributions of up to 2 percent of income for new adults and copayments of up to $25 for non-emergent use of the emergency room. Arizona Health Care Cost Containment System, Arizona’s Application for a New Section 1115 Demonstration (Arizona: Arizona Health Care Cost Containment System, September 2015), hitp://www.azahcces.gov/shared/Downloads/AZWaiverPackageg-30- 15RealFinal.pdf. Nick Lyon, Amendment to Michigan’s Section 1115 Demonstration Known as the “Healthy Michigan Plan” Submitted Under Authority of Section 1115 of the Social Security Act (Michigan: Michigan Department of Health and Human Services, September 1, 2015), http://www.michigan.gov/documents/mdch/CMS HMP 1115 Waiver Amendment Submission 498740_7.pdf. “FY 2016- 2017 State Budget — Health Savings Accounts,” Ohio Department of Medicaid, accessed October 1, 2015, http://medicaid.ohio.gov/INITIATIVES/StateBudget.aspx. 7 In order to impose higher cost sharing than otherwise allowed under federal law, a state needs to meet separate cost sharing waiver requirements under Section 1916(f) of the Social Security Act. Section 1916(f) permits a state to seek a demonstration waiver to charge cost sharing above otherwise allowable amounts if the state meets specific requirements and criteria, including testing a unique and previously untested use of copayments and limiting the demonstration to no longer than two years. Robin Rudowitz, Samantha Artiga and MaryBeth Musumeci, The ACA and Medicaid Expansion Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, February 2015), hitp://kff.org/report-section/the-aca-and-medicaid-expansion-waivers- issue-brief/. 8 Michigan released a waiver proposal in September 2015 based on state legislation calling for those with incomes between 100 and 138% FPL who have had coverage through the Healthy Michigan Plan for 48 cumulative months to be given the choice of either purchasing private insurance through the Marketplace with eligibility for advanced premium tax credits and cost-sharing reductions or remain in Healthy Michigan Plan but with increased cost-sharing and premiums capped at 7% of income (instead of federal maximum of 5%.) Such beneficiaries would also have increased monthly contributions (up to 3.5%) that could be reduced if they complete healthy behavior activities. If approved, this change would not go into effect until April 1, 2018. If this waiver is not approved, state law requires that the Healthy Michigan Plan ends as of April 30, 2016. Nick Lyon, Amendment to Michigan’s Section 1115 Demonstration Known as the “Healthy Michigan Plan” Submitted Under Authority of Section 1115 of the Social Security Act (Michigan: Michigan Department of Health and Human Services, September 1, 2015), http://www.michigan.gov/documents/mdch/CMS_HMP_ 1115 Waiver _ Amendment Submission 498740_7.pdf. ° Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Montana (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, September 2015), http: //kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in- montana/. '0 This is in lieu of the “217-like option” which had been approved by CMS as part of the state’s comprehensive waiver, but proved challenging to implement. 'l Mississippi is included in the counts for states operating MCOs; however, its risk-based managed care program as of July 1, 2015 did not cover inpatient hospital services. Idaho’s MMCP program, which is secondary to Medicare, has been re-categorized by CMS from a PAHP to an MCO by CMS but is not counted here as such. California has a small PCCM program operating in LA County for those with HIV. Wyoming’s Patient Centered Medical Home program uses PCCM authority to make PMPM payments but is not counted here as such, Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 81 '2 California notes that the delivery of substance abuse services is moving to an “Organized Delivery System operated by counties” in FY 2016. For purposes of this report, this new arrangement is treated as a PHP as it is recognized at the federal level. '3 One MCO state (North Dakota) had no children enrolled in its MCO which is limited to Medicaid expansion adults; they are therefore excluded from this count. '4 There are 10 MCO states (DE, GA, HI, ND, NH, NV, TN, TX, VA and WV) that either do not cover adult dental services or only cover emergency dental services for adults. Georgia and Tennessee indicated that MCOs could offer adult dental services as a value-added benefit or cost effective alternative. 'S Maryland indicated that MCOs could offer add-on adult dental plans for non-covered populations. '6 The “Program of all All-Inclusive Care for the Elderly” (PACE) is a capitated managed care benefit for the frail elderly provided by a not-for-profit or public entity that features a comprehensive medical and social service delivery system. It uses a multidisciplinary team approach in an adult day health center supplemented by in-home and referral services in accordance with participants’ needs. ‘7 For purposes of this survey, Idaho Medicare Medicaid Coordinated Plan is considered a PHP rather than an MCO as Medicare provides primary coverage for primary and acute care including inpatient hospital services. '8 Hawaii and Tennessee auto assign all new members to a health plan and then offer them a choice. "9 80 Fed. Reg. 31097-31297 (June 1, 2015), available at https://federalregister.gov/a/2015-12965. 20 Julia Paradise and MaryBeth Musumeci, Proposed Rule on Medicaid Managed Care: A Summary of Major Provisions (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, July 23, 2015), http://kff.org/medicaid/issue-brief/proposed-rule-on- medicaid-managed-care-a-summary-of-major-provisions/. 21 Julia Paradise and MaryBeth Musumeci, Awaiting New Medicaid Managed Care Rules: Key Issues to Watch (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 24, 2015), http: .org/medicaid /issue-brief/awaiting-new-medicaid- managed-care-rules-key-issues-to-watch/. 22 National Association of Medicaid Directors, Comments on Medicaid and Children’s Health Insurance Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies and Revisions Related to Third Party Liability (CMS-2390-P) (Washington, DC: National Association of Medicaid Directors, July 27, 2015), http://medicaiddirectors.org/node/1241, 23 «Patient-Centered Medical Home Recognition,” National Committee on Quality Assurance, accessed October 1, 2015, http://www.ncga.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. 24 Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concept, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured,) June 2015 Fact Sheet. h files.kff. ch fe 25 Kaiser Commission on Medicaid and the Uninsured, Medicaid Delivery System and Payment Reform: A Guide to Key Terms and Concept (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), http://files.kff.org/attachment/issue-brief- medicaid-delivery-system-and-payment-reform-a-guide-to-key-terms-and-concepts. 26 Thid. 27 Steve Eiken, Kate Sredl, Brian Burwell and Paul Saucier, Medicaid | Expenditures for Long-Term Services and Supports (LTSS) in FY 2013 (Truven Health Analytics, June 30, 2015), h dicaid-chi infe b services-and-supports/downloads/Itss- -expenditures-fy2013. D df. 28 The “Program of all All-Inclusive Care for the Elderly” (PACE) is a capitated managed care benefit for the frail elderly provided by a not-for-profit or public entity that features a comprehensive medical and social service delivery system. It uses a multidisciplinary team approach in an adult day health center supplemented by in-home and referral services in accordance with participants' needs. 28 California Department of Health Care Services, DHCS Issues Statement Regarding the Section 811 Project Rental Assistance Demonstration Program (California: Department of Health Care Services, February 2013), http://www.dhcs.ca.gov/Documents/13- 1%20Section%20811%20Demo.pdf. 3° “Conflict-free case management” assures, in part, that the person or entity that conducts the functional assessment and/or case management services for a member does not also provide services to that individual. Single points of entry (SPOE) systems offer consumers one-stop access to information, support, and linkages to local care services thereby reducing service fragmentation and simplifying access to long-term supports and services. 3! Tennessee also reported implementing an individual cost cap in one of its IDD HCBS waivers in FY 2015, but noted that persons whose services exceeded the cap were transitioned to another waiver with an aggregate cost cap so that their services would not be reduced. Also South Carolina) reported temporarily suspending its Certificate of Need program during parts of FY 2014 and FY 2015, but noted that the state did not experience any increases in institutional capacity during that period. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 82 32 Molly O’Malley Watts, Erica L Reaves and MaryBeth Musumeci, Medicaid Balancing Incentive Program: A Survey of Participating States (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2015), http://kiff.org/medicaid/report/medicaid- 33 Until June 2014, Indiana operated as a Section 209(b) state; under Section 209(b) of the Social Security Act, states may develop their own disability determination methods for determining eligibility for aged, blind, and disabled groups. As part of this option, states must operate a spend-down program. In June 2014, Indiana switched to operate as a Section 1634 state, which relies on disability determinations by the Social Security Administration. As a Section 1634 state, Indiana no longer had to operate a spend-down program. 34 New York reported implementing this option in FY 2015, but was awaiting final SPA approval at the time of the survey. The SPA calls for retroactive implementation. New York State Department of Health, State Plan Amendment #13-35 Community First Choice Option (New York: New York State Department of Health, December 30, 2013), 35 Centers for Medicare and Medicaid Services, Fact Sheet: Summary of Key Provisions of the Home and Community-Based Services (HCBS) Settings Final Rule (CMS 2249-F/2296-F) (Washington, DC: Centers for Medicare and Medicaid Services, January 10, 2014), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and- Community-Based-Services/Downloads/HCBS-setting-fact-sheet.pdf 36 An additional state (Pennsylvania) had also not enacted a budget at the time of the survey. The state reported current plans but indicated that final actions depended on the final budget approved by state lawmakers. 3? Rates for FY 2016 not yet determined at the time of the survey included MCO rates for Florida and all rates for Illinois. 38 Tlinois indicated that the rate restriction reported for nursing facilities in FY 2015 reflects a composite of a 10 month increase in rates and a two month decrease in rates. 39 Stephen Zuckerman and Dana Goin, How Much Will Medicaid Physician Fees for Primary Care Rise in 2013? Evidence from a 2012 Survey of Medicaid Physician Fees (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, December 2012), ://kff.org/medicaid/issue-brief/how-much-will-medicaid-physician-fees-for/. “° Some states also have premium or claims taxes that apply to managed care organizations and other insurers. Since this type of tax is not considered a provider tax by CMS, these taxes are not counted as provider taxes in this report. “’ Centers for Medicare and Medicaid Services, CMCS Informational Bulletin: Clarification of Medicaid Coverage of Services to Children with Autism (Washington, DC: Centers for Medicare and Medicaid Services, July 2014), htip://www.medicaid.gov/Federal- Policy-Guidance/Downloads/CIB-07-07-14.pdf. “? New York State Department of Health, State Plan Amendment #13-35 Community First Choice Option (New York: New York State Department of Health, December 30, 2013), hitps://www.health.ny.gov/regulations/state_plans/status/non- inst/original/docs/os_ 2013-12-30 spa_13-35.pdf. “3 In years past, New Mexico was reported as having a PDL. In this year’s survey, the state clarified that while the Medicaid MCOs have their own PDLs, the state does not have its own PDL. “4 In accordance with federal and state law, states pay the lower of (a) the ingredient cost rate plus a dispensing fee; (b) the Federal Upper Limit (FUL) or State Maximum Allowable Cost rate, if applicable, plus a dispensing fee; or (c) the pharmacy’s Usual and Customary Charge. 45 77 Fed. Reg. 5318-5367 (February 2, 2012), available at hitp://www.gpo.gov/fdsys/pkg/FR-2012-02-02/pdf/2012-2014.pdf, “© Centers for Medicare and Medicaid Services, CMCS Informational Bulletin: Medicaid Pharmacy — Survey of Retail Prices (Washington, DC: Centers for Medicare and Medicaid Services, May 31, 2012), http://www.medicaid.gov/Federal-Policy- Guidance/Downloads/CIB-05-31-12.pdf. 4” “Medicaid Covered Outpatient Drug Rule Currently under OMB Review,” National Association of Medicaid Directors Newsletter, accessed August 18, 2015, http://medicaiddirectors.org/node/1249. 48 Brian Bruen and Katherine Young, What Drives Spending and Utilization on Medicaid Drug Benefits in States? (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, December 2014), http: //files.kff.org/attachment/brief-what-drives-spending-and- utilization-on-medicaid-drug-benefits. “9 The Express Scripts Lab, The 2014 Drug Trend Report (Saint Louis, Missouri: The Express Scripts Lab, March 2015), http://lab.express-scripts.com/drug-trend-report/. °° Thid. According to Express Scripts, roughly half of specialty drug expenditures are billed through the medical benefit (rather than the pharmacy benefit) and are not included in its trend calculations. >! State fiscal years begin July 1 except for these states: NY on April 1; TX on September 1; AL, MI and DC on October 1. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 83 NAMD National Association of —— Medicaid Directors FOUNDATION THE HENRY J. KAISER FAMILY FOUNDATION Headquarters 2400 Sand Hill Road Menlo Park, CA 94025 Phone 650-854-9400 Fax 650-854-4800 Washington Offices and Barbara Jordan Conference Center 1330 G Street, NW Washington, DC 20005 Phone 202-347-5270 Fax 202-347-5274 www.kff.org This publication (#8785) is available on the Kaiser Family Foundation’s website at www.kff.org. RU me OOM LC CL Ee the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California. THE NATIONAL ASSOCIATION OF MEDICAL DIRECTORS 444 North Capitol Street, Suite 524 Washington, DC 20001 ABOUT THE NATIONAL ASSOCIATION OF MEDICAL DIRECTORS About NAMD: The National Association of Medicaid Directors (NAMD) is a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories). NAMD is committed to providing a focused, coordinated voice for the Medicaid program in national policy discussion and to facilitate dialogue among its members, and help provide best practices and technical assistance tailored to individual members as they seek to sustain the program and ensure it continues to serve the needs of current and future enrollees. www.medicaiddirectors.org