REGULATORY INTELLIGENCE

YEAR-END REPORT - 2021

Health Policy Tracking Service - Issue Briefs
Medicaid
Medicaid Restructuring

This Issue Brief was written by Tammy J. Raduege, J.D., a contributing writer and member of the Wisconsin bar.
12/20/2021
I], Background

Ensuring the vitality of Medicaid is a priority for President Joseph Biden's Administration. In one of his first acts after being inaugurated,
President Biden (D) issued an executive order to strengthen the program. Section 1 of the order cites the positive effect the Affordable
Care Act has had on reducing the uninsured rate in the country, establishing consumer protections, and strengthening the health care
system. He notes, however, that many eligible people still remain uninsured, and he said that his administration views health care as

a priority: '[I]t is the policy of my Administration to protect and strengthen Medicaid and the ACA and to make high-quality healthcare
accessible and affordable for every American," he wrote.

Section 3 of the order directs all agency heads to review their regulations, policies, guidance documents, and other papers to ensure
that they advance the priorities stated in Section 1:

(a)The Secretary of the Treasury, the Secretary of Labor, the Secretary of Health and Human Services, and the heads of all other
executive departments and agencies with authorities and responsibilities related to Medicaid and the ACA (collectively, heads of
agencies) shall, as soon as practicable, review all existing regulations, orders, guidance documents, policies, and any other similar
agency actions (collectively, agency actions) to determine whether such agency actions are inconsistent with the policy set forth in
section 1 of this order. As part of this review, the heads of agencies shall examine the following:

(ii)demonstrations and waivers, as well as demonstration and waiver policies, that may reduce coverage under or otherwise undermine
Medicaid or the ACA;

(iv)policies or practices that may present unnecessary barriers to individuals and families attempting to access Medicaid or ACA
coverage, including for mid-year enrollment; and

(v)policies or practices that may reduce the affordability of coverage or financial assistance for coverage, including for dependents. [FN2]

President Biden remarked that he is "restoring the Affordable Care Act and restoring the Medicaid [program] to the way it was before
Trump became president, which by fiat he changed, made more inaccessible, more expensive and more difficult for people to qualify for

either of those two items." [FN*I
Il. THE AFFORDABLE CARE ACT

A. Recent Efforts to Repeal and Replace the Affordable Care Act

In March, 2010, President Obama signed two bills into law:H.B. 3590, the Patient Protection and Affordable Care Act of 2010 (P.L.
111-148) and H.B. 4872, the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152), which make comprehensive
changes to Medicaid. The law aims to improve the quality of care, improve the health of the citizenry, and reduce costs. New payment
and delivery models are tailored to achieve these goals. Also, the law places emphasis on decreasing fraud, abuse, and waste.

Since the Affordable Care Act became law more than a decade ago, opponents have been challenging it, both congressionally and in
the courts. The latest challenge was in the courts, with two individuals and governors or attorneys general from several states claiming

 
  

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that the act as a whole was unconstitutional since the Tax Cuts and Jobs Act of 2017 set the minimum essential coverage penalty (or
the individual mandate, the penalty for not having health insurance) to $0. The Justice Department was not defending the case, and it in
fact argued against the law. The case wound through the federal courts, with the lower courts generally agreeing with the plaintiffs, and
it ended up in the Supreme Court. On June 17, 2021, the Supreme Court issued its 7-2 decision, holding that the plaintiffs did not have
standing to bring the lawsuit. As to the individual plaintiffs, the Court held that they did not prove any injury:

Their problem lies in the fact that the statutory provision, while it tells them to obtain that coverage, has no means of enforcement. With
the penalty zeroed out, the IRS can no longer seek a penalty from those who fail to comply. See 26 U. S. C. ?5000A(g) (setting out
IRS enforcement only of the taxpayer's failure to pay the penalty, not of the taxpayer's failure to maintain minimum essential coverage).
Because of this, there is no possible Government action that is causally connected to the plaintiffs' injury-the costs of purchasing
health insurance. Or to put the matter conversely, that injury is not 'fairly traceable" to any 'allegedly unlawful conduct" of which the

plaintiffs complain. [FN4]

The state plaintiffs argued, essentially, that the mandate drove more individuals to enroll in Medicaid or Marketplace plans, causing the
states to incur costs for these programs. The court held that, similar to the individual plaintiffs, the state plaintiffs could not show any
harm from the unenforceable mandate:

The state plaintiffs have failed to show that the challenged minimum essential coverage provision, without any prospect of penalty, will
harm them by leading more individuals to enroll in these programs. [FNS]

Having decided the case procedurally, the Court did not reach the merits. [FN6] The decision means that all the law's consumer
protections, its Marketplace subsidies, the Medicaid expansion, and other important provisions remain in place. According to The New
York Times, had the Court struck down the law, the ranks of the uninsured would have swelled by an additional 21 million people, an

increase of nearly 70%. The bulk of these newly uninsured individuals would have been those who lost coverage from the Medicaid

expansion. [FN7]

Upon hearing of the decision, Health and Human Services (HHS) Secretary Xavier Becerra issued a statement lauding the decision and
the impact it will have on people's lives:

Today's decision means that all Americans continue to have a right to access affordable care, free of discrimination. More than 133
million people with pre-existing conditions, like cancer, asthma or diabetes, can have peace of mind knowing that the health protections
they rely on are safe. Women who need access to birth control, life-saving maternity care and preventive care can rest easy, knowing
that their care is protected and covered. Seniors and people with disabilities can breathe easy knowing their health protections will
continue. Individuals who have faced discrimination can continue accessing care without fear. And people relying on Medicaid and

Medicare should know these programs are stronger than ever. [FN8]

The news of the decision came on the heels of HHS' announcement earlier in June that more people than ever are receiving the
benefits of the Affordable Care Act. Thirty-one million Americans are receiving coverage through one or another of the Affordable Care
Act's programs, including 11.3 million in Marketplace plans, 14.8 million newly eligible individuals in the Medicaid expansion, one million

in the Basic Health Plan, and nearly four million who were previously eligible for Medicaid but unenrolled until Affordable Act provisions

were implemented (such as education and outreach, streamlined enrollment processes, and so forth). [FNS]

B. New Developments on the Medicaid Expansion

As originally passed, the Affordable Care Act included a provision requiring states to expand their Medicaid programs to adults
(including childless adults) earning up to 138% of the federal poverty level. States that refused to do so were at peril of losing all of their
federal Medicaid funds. The United States Supreme Court decided that this provision was unduly coercive, and it made the expansion
optional for states. In subsequent years, many states signed on to the expansion, some by using waivers through which the federal
government gave the states additional flexibility to design their own program. Currently, 39 states (including the District of Columbia)
have adopted the expansion, and 12 states have not. Some states simply implemented the Affordable Care Act's expansion without
change. Other states (including Arizona, Arkansas, Indiana, lowa, Michigan, Montana, New Hampshire, New Mexico, and Ohio)
requested waivers from the Centers for Medicare and Medicaid Services (CMS) to design an expansion program that best-suited their
state. Still others (including Idaho, Maine, [FN10} Missouri, Nebraska, Oklahoma, and Utah) adopted the expansion through a ballot

measure. [FN11] We discuss some of those ballot initiatives below.

As indicated, voters in Utah approved a full Medicaid expansion in November 2018. [FN12] | swmakers then pushed to limit the

expansion, and they successfully passed a bill to do that. """*! The bill is 2019 UT S.B. 96 (NS), which was adopted on February 11,
2019. The state then secured approval from CMS to implement a limited expansion covering all adults up to 100% of the poverty level
(the Bridge Plan). Where the plan approved by voters would have covered individuals with income up to 138% of the federal poverty

level and added about 150,000 to the Medicaid rolls, the Bridge Plan added about 90,000 individuals. "4! when CMS approved the
Bridge Plan, it approved only 70% funding for the partial expansion, which is Utah's ordinary FMAP, N15] instead of the 93% it would
have covered for a full expansion. [FN16]

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In May 2019, Utah filed another waiver seeking full expansion funds for its partial expansion, even though CMS had never granted such

a waiver, 'FN"71 a couple of months later, CMS made clear that it will not grant full expansion funds for partial expansions. The agency
discussed its reasoning in a statement:

[A] number of states have asked CMS for permission to cover only a portion of the adult expansion group and still access the enhanced
federal funding available through Obamacare. Unfortunately, this would invite continued reliance on a broken and unsustainable
Obamacare system. While we have carefully considered these requests, CMS will continue to only approve demonstrations that comply

with the current policy. [FN'18]

Utah later submitted a waiver for its Per Capita Cap Plan, which was to cover individuals with income up to 138% of the federal poverty

level. This plan requested approval to implement, among other things, a per capita cap financing structure and an enrollment cap. [FN19]

The state later submitted a request for its Fallback Plan. In late 2019, CMS approved many provisions of the Fall Back plan, and the

state has now adopted a full Medicaid expansion with work requirements. CMS did not approve a request to implement an enrollment
[FN20]

cap.

Voters in Nebraska also approved the expansion in November 2018, and the ballot initiative provided that no additional eligibility
restrictions or burdens were to be added to the program. After voters approved the measure, the Nebraska Department of Health

and Human Services announced that the expansion would not be implemented until late 2020. It also announced that it was seeking
permission from the federal government to have two 'tiers" of coverage ? basic and prime; the prime tier would include dental,

vision, and prescription coverage. In the first year of the program, participants could qualify for the prime level of coverage by having

a physical, choosing a primary care physician, and engaging in care and case management. In the second year of the program,
participants would have to complete a work requirement to qualify for prime coverage. Proponents of the expansion were angry at the
amount of time the state was taking to implement the expansion and at the additional restrictions placed on coverage. The state argued
that it needed that amount of time to make sure that the program was put in place in a thoughtful manner. [FN21] CMS subsequently
approved Nebraska's Heritage Health Adult demonstration waiver on October 20, 2020, including the two-tiered approach. Community
engagement requirements were to begin 2022, but CMS later rescinded the approval of work requirements in all states that had

them. '-72l The state then announced its plan to withdrew its waiver request and begin offering full benefits for expansion enrollees.
Enrollment in the expansion program began on August 1, 2020, and coverage took effect on October 1. [FN23]

In Montana, the legislature had already passed legislation to adopt the expansion, but it was set to expire in June 2019. A ballot

initiative was put forward to fund the expansion after June with a tax on tobacco, but it narrowly failed. IFN24] Since then, the legislature
passed an expansion bill, and Governor Steve Bullock (D) signed it. The bill contains work requirements, but it was expected that most

people who were eligible through the expansion would be exempt. Still, the work requirements needed CMS' approval. IFN25] Because

approval was pending, the requirements did not take effect on January 1, 2020, as planned. [FN26] th public notice, the Montana
Department of Public Health and Human Services indicated that CMS has already communicated to the state that it would not the
approve work requirements. [FN27] That makes the future of the Medicaid expansion a bit uncertain in Montana. According to Kaiser
Health News, a state health official indicated that, if CMS approves the rest of the waiver, the department will administer the program
until further legislative action. [FN28]

In Idaho, a ballot initiative to adopt the legislation was approved. However, Governor Brad Little (R) signed legislation making changes
to the Medicaid expansion that voters adopted. Among other things, the changes call for work requirements. In Governor Little's letter to
the Senate President indicating that he signed the bill, the governor expressed some reservations about the work requirements, given
that courts have recently halted them in other states, and he believes that the plan may not use existing work and training programs

to implement work requirements more efficiently. He also stated that he thinks the fiscal impact analysis of the bill underestimated the
administrative costs for implementing the requirements. He is, however, very supportive of work requirements in general. The governor

urged the legislature to address his concerns with the bill in its next session. IFN28] The bill also included a 'coverage choice provision"
that would allow those earning between 100% and 138% of the federal poverty level to choose between the Medicaid program and a
plan on the Marketplace with premium subsidies. The state sought a waiver from CMS to implement this provision, but CMS denied

it, FNS] Approval for the work requirements will undoubtedly be denied as the Biden Administration has withdrawn approval of work

requirements in states that already implemented them. The bill is 2019 ID S.B. 1204 (NS), and it was adopted on April 9, 2019. FN31]
Enrollment for the expansion program began on November 1, 2019. According to news reports, enrollment began slowly, with only

about 60,000 of the eligible 91,000 signing up in the first few months. /"N*2! An official with the Idaho Department of Health and Welfare
said that she expected that more people will sign up when they need services. [FN33] As of June 2020, about 80,000 people had signed
up. IFN54] The legislature has now passed a bill making it more difficult to get a measure on the ballot. [FNSS] Litigation ensued, and

the state Supreme Court ruled that the law violated the state constitution. IFN36] Ballot initiatives are running into snags in Florida and
Mississippi as well. In Florida, the group organizing the ballot drive has postponed it to 2022. In Mississippi, the Secretary of State

approved a measure for the ballot in 2022, but the constitutionality of the ballot initiative process is now being heard in court. [FN37]

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Officials in Oklahoma had sought permission to adopt the expansion through a State Plan Amendment. In March 2020, the expansion
was on course to be adopted. The legislature had passed legislation to pay for it, which included an increase in hospital fees. However,
Governor Kevin Stitt (R) vetoed the bills, indicating that the rising unemployment rate (apparently due to the pandemic) caused him to

re-think the expansion given how much it would likely cost, and the state withdrew its State Plan Amendment in late May 2020. [FN38] at
that time, the state's Healthy Adult Opportunity waiver was still pending before CMS. (Please see Medicaid Financing below for more
information about that demonstration.)Then, by a narrow margin, voters approved a constitutional amendment to adopt the expansion

in late June 2020. "N° The measure passed by less than 7,000 votes. [FN40] The text of the ballot initiative provided that additional
eligibility restrictions may not be placed on the expansion group:

B. No greater or additional burdens or restrictions on eligibility or enrollment shall be imposed on persons eligible for medical assistance

pursuant to this Article than on any other population eligible for medical assistance under Oklahoma's Medicaid program. [FN41]

After the election, on August 11, 2020, the state withdrew its Health Adult Opportunity waiver request. [FN42]

The state began enrolling eligible individuals on June 1, 2021, and those enrolled began receiving coverage on July 1. IFN43] So far,

120,000 individuals have enrolled, and the state estimates that a total of about 200,000 are eligible. [FN44] tn a press release heralding
the Oklahoma expansion, HHS Secretary Xavier Becerra noted that, because Oklahoma implemented the expansion when it did, it
will benefit from the financial incentives in the American Rescue Plan: a two-year, five percentage point bump in their regular federal
medical assistance percentage (FMAP) for many Medicaid services. CMS estimates that the state will receive nearly $500 million over
two years in addition to the 90% FMAP it receives for expansion individuals. Secretary Becerra congratulated the state on taking this
step:

Today is a victory for the nearly 200,000 Oklahomans who have been waiting for health care. . . . | want to congratulate Oklahoma on

joining the ranks of states that are bringing quality health coverage to our neighbors and families. | encourage the remaining 13 states

to look at the opportunities included in the American Rescue Plan and join us, so that every person eligible can get covered. [FN45]

With a nod to CMS' focus on health equity, CMS Administrator Chiquita Brooks-LaSure remarked,

'Medicaid is a lifeline for millions of people in this country and a step in the long road to achieving health equity by providing access to
essential health care . . .. Oklahoma is now a model for other states looking to expand health coverage to those who need it most."
[FN46]

As National Public Radio reported, on August 4, 2020, voters in Missouri adopted the Medicaid expansion through a ballot initiative
that amended the state constitution. The measure passed by a vote of 53.25% to 46.75%. It was overwhelmingly supported in larger
urban areas, but many rural voters opposed the measure, even in areas with high rates of uninsured residents. Opponents worried that
if too many people sign up, the state's 10% share of the cost for the newly insured could become a burden, requiring the state to make
cuts in other areas. Supporters of the expansion argued that health insurance is particularly crucial now, during a pandemic, and the
influx of the additional federal funds (90% of the cost for the newly insured) will spur economic activity. An analysis in 2019 concluded

that 230,000 individuals would qualify if an expansion were adopted. [FN47] th @ few other states that have adopted ballot measures,
legislators have later added restrictions to the programs, like work restrictions, among other things. This was true in Idaho and Utah. In
Missouri, however, the constitutional amendment prohibits any additional restrictions from being placed on eligibility, apart from income

and immigration status. [FN48] Despite that fact, the legislature failed to allocate funds for an expansion, and the state announced that

it was withdrawing its State Plan Amendment. Litigation ensued, and the state Supreme Court ruled in favor of the plaintiffs. [FN49] The
state began accepting applications in August 2021 and began processing them on October 1. Those who are determined eligible will

have coverage retroactive to July 1. [FNSO}

In a press release, HHS noted that roughly 275,000 people will be eligible for coverage through the expansion, and so far about 17,000
have applied. CMS is encouraging all potentially eligible people to apply. CMS Administrator Chiquita Brooks-LaSure remarked,

'Medicaid in Missouri has expanded, and | encourage eligible Missourians to apply . . . . Thanks to the Affordable Care Acct, eligible
Missourians can now sign up for the health care they need. MO HealthNet's expansion will put comprehensive health coverage within
reach for more than 275,000 additional Missourians. We will continue to encourage remaining states to extend the lifeline of Medicaid

coverage to all who need it." [FNS1]

Because of the incentive for newly expanding states in the American Rescue Plan (P.L. 117-2), Missouri can expect to receive an
additional $968 million in federal Medicaid funds over the next two years. [FNS2]

Arkansas also makes expansion news. The state was an early adopter of the Medicaid expansion, implementing it with a waiver that
the state designed along with the Obama Administration. That iteration of the expansion, the Health Care Independence Program,
was novel at the time as it used expansion funds to buy insurance on the private market for expansion enrollees. When that program
expired, it was replaced with a program called Arkansas Works, which imposed work requirements and shortened the period for
retroactive coverage. Once the work requirements were implemented, the program suffered substantial coverage losses, and a court

 
  

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halted the requirements. The Arkansas Works program is due to expire at the end of the year, and the state wishes to replace it with the
Arkansas Health and Opportunity for Me (HOME) program. Enrollees would be entitled to Marketplace coverage. Work requirements
would not be imposed as a condition of eligibility, but participants who do not engage in work activities could be placed into the

Medicaid fee-for-service program. The state would impose premium and cost-sharing obligations. The state has made an allocation for

the program, but approval is pending with the Biden administration. [FNS3)

In Kansas, the governor has twice proposed a Medicaid expansion, but the legislature has failed to act on it. The latest proposal was
in line with a bipartisan plan that included work referrals and premium requirements, and it was to be funded with a medical marijuana

sales and taxes, '"N°4l Ultimately, no bill passed before the legislature adjourned.

The American Rescue Plan (ARP) (P.L. 117-2) created an additional incentive for non-adopting states to adopt and implement

the expansion:lt offers a two-year five-percentage-point increase in the state's FMAP [FNS5I for its current Medicaid program plus a
permanent 90% FMAP for the newly eligible. According to the Center on Budget and Policy Priorities, the two-year increased FMAP for

the existing Medicaid program would offset states' costs (10%) for the newly insured. [FNS6]

The Commonwealth Fund has published a brief highlighting the value of the ARP's added incentive for the states that have not yet

implemented the expansion. IFNS7] Above all, accepting the offer allows most of these states to cover hundreds of thousands more
individuals; in South Dakota and Wyoming, the less populated states, tens of thousands would gain coverage. As a group, in 2022
alone, the federal government would contribute $8.5 billion to the newly adopting states for their current programs and $43.8 billion for
the newly eligible. During 2022, those states would be required to contribute about $5 billion. The brief also gives estimates of the state
and federal costs for the period running from 2022 and 2025. At the same time that states would receive these additional federal funds,
they would need to expend less on uncompensated care. Moreover, in 2022, the newly adopting states could see more than 800,000
new jobs. The job growth would appear mostly in health care but would also appear in industries like construction, retail, and finance,
among others. The brief also examines how newly adopting states could benefit in other measures of economic growth:

If the 14 states expand Medicaid, from 2022 to 2025 state output will rise by more than $600 billion, state gross products will increase
by $350 billion, and personal incomes will grow by $218 billion in these states. Additional improvements will accrue to the rest of the

nation, too. [FN58]
Ill. MEDICAID AND STATE BUDGETS and priorities

As it does each fall, the Kaiser Family Foundation published its 50-state budget survey in October 2021, this one addressing policy
changes and trends for fiscal years 2021 and 2022. Naturally, the authors highlighted emergency changes that states made to meet
the demands of the COVID-19 pandemic. However, they also addressed non-emergency changes and the changes that states intend
to make permanent after the public health emergency period ends. Additionally, they discuss what lies ahead in state programs. The
authors organized their findings into five categories:delivery systems, benefits and telehealth, social determinants of health, provider

rates and taxes, and pharmacy. [FNS] Forty-seven states responded to at least a portion of the survey. Below we summarize some of
the findings in these categories as they relate to Medicaid Restructuring.

Delivery Systems

The authors' discussion of delivery systems focused on managed care. According to the authors, states' use of managed care has been
steadily increasing in the past two decades, but enrollment increased during the pandemic, concurrent with the increased enrollment in
Medicaid overall. Currently, capitated managed care is the predominant model in state Medicaid programs. Only four states (Alaska,
Connecticut, Vermont, and Wyoming) do not use some form of managed care in their Medicaid programs. Most states contract with a
managed care organization (MCO) while others use a primary care case management program (PCCM), and a few use both forms. Of
those states that contract with MCOs, most report that 75% or more of their Medicaid populations are covered by managed care. Some
of the changes in state managed care programs include these:

¢ In 2021, North Carolina implemented its first MCO program, which operates statewide and offers integrated physical and behavioral
health services. Enrollment is mandatory for most individuals.

¢ Four states (Arizona, Illinois, Kentucky, and New York) reported making managed care changes for children in foster care.

¢ The District of Columbia expanded mandatory managed care to additional targeted populations in fiscal year 2021, and Tennessee
plans to do so for fiscal year 2022.

¢ Three states (Maine, North Carolina, and Oregon) reported changes to their PCCM programs. In fiscal year 2021, North Carolina
implemented a new PCCM option for certain Indian Health Services-eligible Medicaid participants. Oregon intends to implement a
similar program for fiscal year 2022, and Maine intends to terminate a PCCM program in 2022.

¢ In 2021, Texas ended its non-emergency medical transportation prepaid health plan and carved these services into its MCO plans.

¢ Illinois expanded its Medicare-Medicaid Financial Alignment initiative on July 1, 2021, and participants will receive benefits through a
single Medicare-Medicaid MCO.

 
  

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Social Determinants of Health

Social determinants of health are non-health factors that nevertheless affect our health. The authors define the term as follows:'Social

determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health." [FN60] Foy
years, both the federal government and the states have recognized the importance of addressing social determinants of health

to improve individual and population health. The pandemic, however, laid bare our health system's failings in this regard:Poorer
communities, and especially communities of color, were disproportionately affected by COVID-19. Because Medicaid insures so many
people affected by these disparities, the authors argue that the Medicaid program and MCOs are important players in the quest to
vaccinate more people against the virus. Moreover, initiatives that address social determinants of health can improve health outcomes.
Federal Medicaid rules do not permit states to pay for non-medical expenditures, but states have developed strategies to identify and
address the social needs of their participants. The majority of states that contract with MCOs report using those contracts in 2021

for such purposes, including, 'screening enrollees for behavioral health needs, providing referrals to social services, partnering with

community-based organizations (CBOs), and screening enrollees for social needs." [FN61]

According to the authors, more than one-half of the states that responded to the survey reported that the pandemic led them to
implement, expand, or reform initiatives aimed at addressing social determinants of health. The brief highlights such efforts in Arizona,
California, and North Carolina. Moreover, many states have or plan to implement workforce initiatives to expand the number of
community health workers; the authors say that these workers play an important part in addressing social determinants of health.

Five states (California, Illinois, Louisiana, Nevada, and Wisconsin) plan to add community health worker services as a covered
benefit in fiscal year 2022.

Three states (Arizona, California, and Illinois) and the District of Columbia report adding or planning to add community health
workers as a provider type.

Colorado and Oregon report that they are integrating community health workers in their case management redesign/care coordination
improvement efforts. [FN62]

Additionally, many states (three-quarters of responding states) report having established or having plans to establish initiatives aimed at
addressing health disparities by race or ethnicity. [FN63]

Provider Rates and Taxes

As is often said of Medicaid, it is countercyclical, meaning that in lean economic times, states reduce provider payment rates as a
way to contain costs in their Medicaid programs, and in better economic times, states can afford to increase rates. According to the
authors, however, despite the economic downturn brought about by the pandemic, states found it less feasible to cut payments rates

when providers were financially strained. IFN64] In fiscal year 2021, more states increased fee-for-service payment rates for at least

one provider category than implemented payment restrictions (42 states and 27 states, respectively). For fiscal year 2022, 45 of the
responding states reported plans to increase rates in at least one area, and 26 planned to implement restrictions. When states did
increase fee-for-service rates, it was often in nursing facility and home- and community-based services provider categories. As for rate
reductions, in fiscal year 2021, Colorado and Wyoming implemented rate reductions across most provider categories. For fiscal year
2022, California, Idaho, and North Carolina reported plans to reduce rates across most provider categories. And in Mississippi,
the legislature enacted a rate freeze for all providers for fiscal years 2022 through 2024. The authors highlight fee-for-service
rate increases among some common provider categories for fiscal years 2021 and 2022:

Inpatient hospitals:21 states adopted increases in 2021, and 24 states have adopted them for 2022.

Nursing facilities:39 states adopted increases in 2021, and 37 states have adopted them for 2022.

Home- and community-based services:30 states adopted increases in fiscal year 2021, and 39 have adopted them for 2022.
Outpatient hospitals:21 states adopted increases in fiscal year 2021, and 24 states have adopted them for 2022.

Primary care physicians: 19 states adopted increases in fiscal year 2021, and 15 states have adopted them for 2022.
Specialist physicians: 15 states adopted increases in fiscal year 2021, and 15 states have adopted them for 2022.
OB/GYNs: 13 states adopted increases in fiscal year 2021, and 13 states have adopted them for 2022.

Dentists:14 states adopted increases in fiscal year 2021, and 16 states have adopted them for 2022.

In terms of decreases in provider rates in fiscal years 2021 and 2022:

Inpatient hospitals:26 states adopted decreases in 2021, and 23 states have adopted them for 2022.

Nursing facilities:8 states adopted decreases in 2021, and 10 states have adopted them for 2022.

Home- and community-based services:4 states adopted decreases in fiscal year 2021, and 2 have adopted them for 2022.
Outpatient hospitals: 4 states adopted decreases in fiscal year 2021, and 2 states have adopted them for 2022.

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Primary care physicians: 2 states adopted decreases in fiscal year 2021, and 3 states have adopted them for 2022.
Specialist physicians: 2 states adopted decreases in fiscal year 2021, and 3 states have adopted them for 2022.
OB/GYNs: 2 states adopted decreases in fiscal year 2021, and 3 states have adopted them for 2022.

Dentists:2 states adopted decreases in fiscal year 2021, and 2 states have adopted them for 2022.

Of states reporting rate changes, the majority indicated the changes were made in whole or part because of the pandemic. [FN65]

Fee-for-service payment rates often serve as benchmarks for managed care capitation rates. Please see the Issue Brief for information
about payment changes in managed care.

Finally, the authors report that states continue to rely on provider taxes and fees to fund some of the state portion of Medicaid costs.
Pharmacy

According to the authors of the Kaiser Family Foundation's 50-state survey, the way states implement the Medicaid pharmacy benefit
has changed over time, with states delivering the benefit through fee-for-service and managed care, and some have come to rely on
pharmacy benefit managers to administer certain functions, including 'negotiating rebates with drug manufacturers, adjudicating claims,

monitoring utilization, overseeing preferred drug lists[.]"States contract with these managers in both fee-for-service and managed care

programs. These organizations have come under scrutiny of late due to concerns with transparency. IFN66]

Managed care plays a big role in administering the pharmacy benefit. According to the authors, the vast majority of states that use
managed care choose to carve these benefits into their managed care programs. (Many have targeted carve-outs of certain drug
classes, however. )This is true in 35 of the 41 states that have contracts with MCOs. However, five states (Missouri, North Dakota,
Tennessee, Wisconsin, and West Virginia) have carved this benefit out of their managed care contracts as of July 1, 2021, and three
states (California, New York, and Ohio) have plans to do so in fiscal year 2022 or later. Kentucky is using a 'hybrid" approach:

Instead of implementing a traditional carve-out of pharmacy from managed care, in FY 2022, Kentucky began contracting with a
single PBM for the managed care population. Under this 'hybrid' model, which the state reports is the first of its kind, MCOs remain at
risk for the pharmacy benefit but must contract with the state's PBM to process pharmacy claims and pharmacy prior authorizations
according to a single formulary and PDL. Louisiana reports that it is moving to a similar model in FY 2022, and will require MCOs

to contract with a single PBM designated by the state. [FN67]

According to the authors, specialty and high-cost drugs are responsible for most of the growth in prescription drug prices, and they
remain a concern for state Medicaid programs. Many states report that they are working toward value-based purchasing arrangements
with drug manufacturers, but only six states (Alabama, Arizona, Massachusetts, Michigan, Oklahoma, and Washington) have such
arrangements in place with one or more manufacturers. Many states report implementing or having plans to implement one or more
cost containment strategies for prescription drugs, including these:

Medication therapy management (California, Oklahoma, and Texas)

Strategies to eliminate Hepatitis C, a condition that is treated with high-cost drugs (Michigan and Missouri)
Pharmacy reimbursement adjustments (Alabama, Alaska, Colorado, Kansas, and Kentucky)

Reducing dispensing costs by extending the covered days' supply (Alaska, West Virginia, and Wyoming)

Program integrity (Missouri)

Providing resources and tools for providers (Colorado and Oklahoma) [FN68]

Please see the Issue Brief for a much fuller discussion of states' policies for the pharmacy benefit.
IV. Work Requirements and other Controversial Features of Waivers

Section 1115 of the Social Security Act allows the HHS Secretary to waive Medicaid program requirements for experimental, pilot, or
demonstration programs that are likely to promote the objectives of the Medicaid program. Previous administrations have interpreted
this to mean that the waiver program must be designed to expand coverage. Therefore, the government had never before approved
program features like work requirements, which could actually limit coverage. The Trump Administration, however, did not require such
proof. According to a brief from the Kaiser Family Foundation,

revised waiver criteria focus on positive health outcomes, efficiencies to ensure program sustainability, coordinated strategies
to promote upward mobility and independence, incentives that promote responsible beneficiary decision-making, alignment with

commercial health products, and innovative payment and delivery system reforms. [FN6S]

President Biden's Administration views waivers much the way that previous administrations had before the Trump Administration. As
discussed below, we are starting to see Biden Administration's philosophy on waivers taking shape as it seeks to undo policies put in
place under former President Trump.

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The Trump Administration's shift in waiver policy was apparent in the way it treated waiver requests approving work requirements

in Medicaid. Seeing the writing on the wall, ten states, Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire,
North Carolina, Utah and Wisconsin, had submitted proposals seeking to impose work requirements before CMS formally issued
guidance on the matter. In January 2018, CMS issued guidance specifically approving such approaches and setting out guidelines for

including them in state Medicaid programs. [FN70] CMS firmly believed that education, higher income, and employment are all social
determinants of health, so allowing states to impose work/community engagement requirements are all in keeping with sound Medicaid
policy. Opponents said that the requirements would result in a loss of coverage for the people who need it most, owing to their social
circumstances and the bureaucracy around reporting requirements.

States that received waivers for work requirements include Arizona, Georgia, Indiana, Nebraska, Ohio, South Carolina, Utah,

and Wisconsin. Some states (Kentucky, Arkansas, Michigan, and New Hampshire) had approved waivers, but courts have set
aside their work requirements. (New Hampshire had earlier voluntarily suspended its program because so many people were
on track to lose coverage.)When President Trump left office, waivers were pending in Alabama, Idaho, Mississippi, Montana,
Oklahoma, South Dakota, and Tennessee. Virginia had applied for a waiver to add work requirements to its Medicaid expansion

program, but Governor Ralph Northam (D) formally withdrew that request on July 1, 2020. [FN74]
In February 2021, the Biden Administration sent letters to states with approved waivers, explaining that it had preliminarily determined

that the waivers do not advance the objectives of the Medicaid program. [FN72] According to the Kaiser Family Foundation, CMS

has now sent letters to Arizona, Arkansas, Indiana, Michigan, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin
notifying them of CMS' final decision to disapprove work requirements. After the February 2021 letter, Nebraska withdrew its waiver
and Georgia announced plans to delay implementation of their waiver. Waiver approval is pending in Idaho, Mississippi, Montana,

Oklahoma, South Dakota, and Tennessee. [FN73]

The Kaiser Family Foundation's Waiver Tracker includes links to the letters that CMS sent to the states. The contents of the letters vary
by state, but they often mention things such as widespread and rapid coverage losses, that many subject to the required are confused
or unaware of them, that early research in states that have the requirements does not indicate a substantial increase in employment,
and that wide disparities exist in access to computers or the internet. Please follow the links for more information about each state's

letter, N74]

Work requirements have not fared well in litigation, with courts setting aside the requirements in four states (Arkansas, Kentucky,

Michigan, and New Hampshire). [FN75] The matter is now pending before the United States Supreme Court. The Department of Health
and Human Services (HHS) had asked the Court to vacate the court appeals' decision setting aside the requirements in Arkansas and

New Hampshire and to send the matter back to HHS, but the Court opted to keep the case. [FN76] However, in March 2021, the high
court indicated that it would not hear arguments on the case. [FN77]

Not everyone is pleased with the announcement. The attorney general in Arkansas, for example, called it an 'overreach of executive
authority," and said that the 'one-size-fits-all" approach to Medicaid does not work. [FN78]

On a related note, the Kaiser Family Foundation has released an interactive map of states with approved or pending Medicaid waivers.
[FN79]

In another reversal of Trump Administration policy, the Biden Administration has rescinded its approval of a waiver extension that the
Trump Administration had approved. In the waning days of the Trump Administration, Texas sought a five-year extension of its Section
1115(a) demonstration titled 'Texas Healthcare Transformation and Quality Improvement Program."The request included significant
changes to the waiver. Texas sought approval of the extension in 2020. It was already authorized until 2022, and the state requested
an extension until 2027. The state indicated that extension of the waiver without notice and comment was necessary to ensure stability
for providers and the Medicaid program in the wake of the COVID-19 emergency period, and it therefore sought an exemption. In early
2021, CMS approved the request, even approving features that the state had not requested, like an uncompensated care pool and an
extension until 2030. Though the state sought and received an exemption from the federal notice and comment process, it did engage

in some state-level notice and comment procedures, but the notice materials included details about the waiver extension as requested,

not as ultimately granted, "NS

On April 16, 2021, CMS rescinded the approval, noting that the request did not meet the standard for exemption from notice and
comment:

We have determined that the state's exemption request did not articulate a sufficient basis for us to conclude that approving the
state's emergency request for an exemption from the normal public notice process was needed to address a public health emergency
or other sudden emergency threat to human lives, as required under 42 C.F.R. ? 431.416(g). The state's exemption request in its
application did not establish that the request to extend the demonstration, which was already authorized through September 30, 2022,
was subsiantially related to the public health emergency for COVID-19 or any other sudden emergency threat to human lives, that the
circumstances surrounding the extension request constituted an emergency, or that delay sufficient to complete the public notice and
comment process before approval of the extension request would have undermined or compromised the purpose of the demonstration

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or been contrary to the interest of beneficiaries. Rather, the erroneous initial determination to approve an exemption from the normal
public notice and comment requirements was itself contrary to the interest of beneficiaries, as well as of Texas and CMS, because it
deprived beneficiaries and other interested stakeholders of the opportunity to comment on, and potentially influence, the state's request

to extend a complex demonstration ? already authorized through September 30, 2022 ? into the next decade. [FN81]

Moreover, had the state truly needed to change the waiver to respond to the COVID-19 crisis, it could have used the streamlined
Section 1115 template that CMS had set up for that purpose at the beginning of the emergency period, the agency wrote. It rescinded

approval of the extension and invited the state to resubmit the request after following normal notice and comment processes. [FN82]

At stake are billions of dollars of federal Medicaid funding, which were largely meant to address uncompensated care costs. The state
has so far resisted adopting the Affordable Care Act's Medicaid expansion. IFN83] Because the state has such a high uninsured rate,
[FN84] hospitals suffer significant uncompensated care costs. The Houston Chronicle writes that the state has relied on waivers as a

'cheaper' alternative to expanding Medicaid. [FN85] The federal government is keen on getting the hold-out states to adopt the Medicaid
expansion, and it included in the American Rescue Plan incentives for the states to do so now. According to the paper, the there is no

movement in state government to do so. Nl

According to the Houston Chronicle, health advocacy groups and some health policy experts were opposed to CMS approving the
waiver without notice and comment, with one pointing out that the waiver was never meant to be a permanent fix. Several people
opposed to the waiver extension argued that it is time to seriously consider the expansion as a permanent solution. On the other
hand, the president of the Texas Hospital Association expressed his disappointment in the Biden Administration's decision, saying

that it threatens the state's safety net and the ability of hospitals to protect patients. [FNE7] Becker's Hospital Review writes that the
government's decision to rescind approval of the waiver extension is 'credit negative" for state hospitals. For large urban hospitals, the

waiver accounts for 10-15% of their revenue. "N®!
V.MEDICAID FINANCING

Republicans have always favored block granting Medicaid. The unsuccessful repeal and replace plans would have changed Medicaid
financing to block grants or per capita caps. During the Trump Administration, on January 30, 2020, CMS announced its Healthy Adult
Opportunity. States participating in this demonstration could experiment with a block-grant-type arrangement for the adults in the
Medicaid expansion population and other optional groups. CMS explained the population the demonstration targets:

HAO [Healthy Adult Opportunity] is available to all states, with a focus on a limited population ? adults under age 65 who are not eligible
for Medicaid on the basis of disability or their need for long term care services and supports, and who are not eligible under a state
plan. Other very low-income parents, children, pregnant women, elderly adults, and people eligible on the basis of a disability will not be

directly affected ? except from the improvements that result from states reinvesting savings into strengthening their overall programs.
[FN89]

States participating in the demonstration would be granted additional flexibilities as they designed their programs, allowing states to, for
example:

Adjust cost-sharing requirements to incentivize high value care,

Align benefits more closely to what is available through a commercial insurance benefit package,

Improve negotiating power to lower drug costs by adopting a closed formulary similar to those provided in the commercial market . . . ,
Make timely programmatic adjustments without additional federal approval,

Apply additional conditions of eligibility which support the objectives of the program,

Deliver care through innovative delivery systems, and

Waiving retroactive coverage and hospital presumptive eligibility requirements. [FN90]

In return, states would need to agree to stay within a certain budget, based either on a total expense or per-enrollee methodology.
Expenses that exceeded the target cost would not be eligible for federal funds, but the demonstration also included the possibility of a

shared savings arrangement between the state and the federal government. [FNO1]

[FN82] as well

CMS saw the demonstration as a way for states to deliver better care, achieve better outcomes, and control costs,
as to design a program without undergoing the time and effort that the waiver process requires. [FNS3] Opponents argued that the
demonstration would allow states to limit benefits and access to needed drugs. Litigation over the program is expected. [FNS4]

The Kaiser Family Foundation published a brief highlighting the particulars of the demonstration and pointing out the consequences
of the flexibility that the demonstration offers. For example, states that participate in the demonstration may offer less comprehensive
coverage than currently required, establish a closed formulary for prescription drugs, impose premiums and cost-sharing as a condition

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of eligibility, and implement other eligibility limitations. If the participating state has adopted the Affordable Care Act's Medicaid
expansion, it is limited in the restrictions it may impose on that population if it wishes to continue receiving enhanced expansion funds.

[FN95] However, states that have not adopted the expansion may be willing to expand their programs if they can cap expenses and
impose the types of limitations they wish. [FNS6]

Shortly after the Healthy Adult Opportunity demonstration was announced, Oklahoma sought permission to implement the program as
a part of a Medicaid expansion, but the state withdrew the request after voters approved a traditional Medicaid expansion. [FNS7]

In early 2021, at the end of President Trump's term, CMS approved a ten-year waiver for Tennessee to implement a block grant-type
financing structure for its TennCare program. Typically, states receive federal Medicaid funding using a percentage matching rate (an

FMAP, or federal medical assistance percentage). Tennessee's FMAP is just over 66%. [FN88] The traditional FMAP payment is open-
ended. Instead, Tennessee will receive an aggregate cap amount for five eligibility groups: disabled individuals, children, adults over

the age of 65, adults under the age of 65, and dual eligible individuals (those eligible for both Medicare and Medicaid). IFN®S] The cap
will be adjusted for inflation, and, importantly, for enrollment growth. If the state spends less than its cap, it can share in up to 55% of
the savings, which can be used for additional services for vulnerable populations, such as services that address the social determinants

of health. (It would also be financially responsible if costs exceed the cap.) [FN100] Additionally, in exchange for agreeing to the cap,
the state will receive program flexibilities that most states do not have, like making certain changes without CMS approval. However,

while the state may add services with CMS approval, it cannot cut services without approval. IFN101l The state sought approval to run
the program indefinitely, but CMS approved it for ten years, still longer than the three- to five-year period usually approved by previous
administrations.

Interestingly, the waiver contains a provision allowing CMS to withdraw approval if it determines that the demonstration is no longer in
the public interest of if it no longer appears to satisfy the objectives of the Medicaid program. The state would be entitled to a hearing

in such a case. *N'°2] Even if the Biden Administration does not choose to withdraw approval for the Tennessee waiver, it might be the
subject of litigation, just like the Trump Administration's work requirement waivers have been. Work requirements have not fared well in
litigation, and they have been halted in four states. Timothy Jost has written a post for the Commonwealth Fund about the health care

litigation that President Biden inherited. "1°"!

The Tennessee waiver was not granted as a part of CMS' Healthy Adult Opportunity demonstration, which allows a block grant-
type financing structure. So far, no state has an approved waiver under that program. That program is primarily meant for expansion

populations; Tennessee has not adopted the Medicaid expansion. [FN104]

It is unclear whether the Healthy Adult Opportunity demonstration or other block grant-type arrangements will survive under the Biden
Administration. Block grants and other types of capped financing structures have traditionally been a favorite of Republican officials,

though this is not universally true. [FN105] Moreover, President Biden's wide-ranging Executive Order affirmed the administration's
commitment to Medicaid and the Affordable Care Act and directed agencies to identify policies that reduce coverage under Medicaid
or present a barrier to Medicaid coverage. Block grant-type demonstrations like the Health Adult Opportunity Demonstration and the

Tennessee waiver may well be highly scrutinized. [FN106] Already, Democrats in Tennessee have asked President Biden to rescind the

waiver, [FN107] and the waiver is being challenged in court. [FN108]

VI. medicaid INNOVATIONS

A. Health Homes

Section 2703 of the Affordable Care Act created a state option in Section 1945 of the Social Security Act for Medicaid Health Homes to
coordinate care for Medicaid participants who:

Have 2 or more chronic conditions
Have one chronic condition and are at risk for a second
Have one serious and persistent mental health condition

The chronic conditions listed in the Act include mental health, substance abuse, asthma, diabetes, heart disease and having a BMI of
over 25. States may request CMS approval to amend their State Plans to include other conditions, like HIV/AIDS. States will receive a
90-10 match rate for health home services for the first two years. Health home services include:

Comprehensive care management

Care coordination

Health promotion

Comprehensive transitional care/follow-up

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Patient & family support

Referral to community & social support services [FN109]

CMS lists the states that currently have approved State Plan Amendments for health homes. For each such state, the table also lists
the model type, the target populations, the health home providers, the enrollment requirements (i.e., opt-in or opt-out), the payment
model, and the geographic area in which the health home operates. The following states have these health home models: California
(chronic conditions and severe mental illness), Connecticut (severe mental illness), Delaware (severe mental illness and intellectual
and developmental disabilities), the District of Columbia (severe mental illness and chronic conditions), lowa (chronic conditions

and severe mental illness), Kansas (chronic conditions and severe mental illness), Maine (chronic conditions, severe mental illness,
and substance use disorder), Maryland (severe mental illness and substance use disorder), Michigan (severe mental illness, chronic
conditions, and substance use disorder), Minnesota (severe menial illness/serious mental disorder), Missouri (chronic conditions
and severe mental illness), New Jersey (severe mental illness in adults and serious emotional disturbance in children), New Mexico
(severe mental illness/serious emotional disturbance), New York (severe mental illness and chronic conditions, and chronic conditions
only), Oklahoma (severe mental illness in adults and serious emotional disturbance in children), Rhode Island (chronic conditions and
severe menial illness, severe mental illness, and opioid dependency), South Dakota (chronic conditions and severe mental illness),
Tennessee (severe mental illness), Vermont (opioid dependency), Washington(chronic conditions), West Virginia (severe mental

illness and chronic conditions), and Wisconsin (AIDS/HIV). [FN110}

CMS has published resources providing guidance on the Health Home Medicaid State Plan Option. First, CMS has provided an FAQ
document covering various definitions; enrollment and certification standards; the provider delivery system; quality measurement and

evaluation; and payment. IFN111] Other documents added to the Health Home Resource Center include a health home map; a Fact
Sheet; a health home State Plan Amendment Overview by state; and an FAQ sheet with a list of chronic conditions that states have

been approved to target. [FN112]
B. Value-Based Payments

Since the Obama Administration, CMS has focused on paying for the quality of care rather than the quantity of care. In other words,

the government wants to pay for value ? quality care with lower costs. Mostly, these programs have been implemented in the Medicare
program. However, in 2020 CMS issued guidance to states on how they can foster a value-based care program by implementing value-
based payment arrangements in their state Medicaid programs. The guidance was in the form of a State Medicaid Director Letter.

IFN113] ina press release, CMS explained how value-based care can improve care for Medicaid participants, especially now, during the
COVID-19 pandemic:

Under value-based care, providers are reimbursed based on their ability to improve quality of care in a cost-effective manner or lower
costs while maintaining standards of care, rather than the volume of care they provide. Value-based care arrangements may also
permit providers to address social determinants of health, as well as disparities across the healthcare system. Moving toward a more
value-driven healthcare system allows states to provide Medicaid beneficiaries with efficient, high quality care, while improving health
outcomes. Value-based care may also help ensure that the nation's healthcare system is better prepared and equipped to handle

unexpected challenges, including the ongoing COVID-19 pandemic. [FN114]
Strategies for achieving value-based care include, for example:

* A fee-for-service payment structure in which the state can adjust payments based on performance, which may include an opportunity
for shared savings (bearing upside and/or downside risk).

¢ Payments based on episodes of care.
« Accountable care.

CMS indicated that it was not announcing any new value-based care programs; rather, the guidance was pointing out opportunities that

states already have, though they may require a State Plan Amendment or a demonstration waiver. [FN115]

C. State Waivers

CMS announced that it approved Georgia's Section 1115 waiver called Pathways to Coverage. The demonstration will offer a Medicaid
opt-in opportunity for adults earning up to 100% of the poverty level who satisfy a work requirement and pay premiums. CMS' press
release describes the individuals who will be eligible:

In order to qualify for this program, individuals must comply with specific requirements, including participating in 80 hours a month of
work or other qualifying activities. Most individuals with income between 50 and 100 percent of the FPL will be required to make initial
and ongoing monthly premium payments. Applicants and beneficiaries with disabilities requiring reasonable accommodation will have

options available to complete and report their qualifying activities and hours. The state is providing support to those not already working

to encourage and enable those beneficiaries to obtain employment and take part in other education and job-supporting activities. IFN116]

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Georgia has not adopted the Affordable Care Act's Medicaid expansion, but this demonstration will allow more individuals to access
Medicaid coverage. CMS estimates that 30,000 will enroll in the demonstration in the first year, and over the five-year course of the

demonstration, 65,000 will gain Medicaid or receive Medicaid premium assistance for employer-sponsored coverage. IFN117] The Kaiser
Family Foundation reports that Georgia sought full expansion funds for their partial expansion, but CMS did not approve the request.

The agency has previously denied states full expansion funds for partial expansions. [FN116]

[FN119]

CMS announced that it approved Section 1115 substance use disorder (SUD) demonstration waivers for both Oklahoma and

Maine. """7°l Both demonstrations - Oklahoma's Institutions for Mental Diseases Waiver for Serious Mental Illness/Substance Use
Disorder and Maine's Substance Use Disorder Care Initiative - authorize federal funds for SUD treatment in an Institution of Mental
Disease ? an inpatient mental health facility with more than 16 beds. Medicaid does not normally pay for such services, but CMS has
approved payment for these services in demonstrations. According to CMS' press release, these demonstrations are the 30th and 31st

demonstrations approved since CMS streamlined the application process for SUD demonstrations in 2017. [FN121] Oklahoma is also

taking advantage of a demonstration opportunity announced in 2018 [FN122] + cover services in an IMD for adults with severe mental
illness and children with a severe emotional disturbance. According to CMS, Oklahoma is the seventh state to have authority under
both the Serious Mental Illness/Serious Emotional Disturbance demonstration waiver and the SUD demonstration waiver. In a press
release, CMS explains how these approvals are consequential:

The approval of these demonstrations opens the door to critical treatment options including continuity of care in the community
following episodes of acute care in hospitals and residential treatment facilities that qualify as Institutions of Mental Diseases (IMDs) as
it allows the Oklahoma and Maine Medicaid programs to overcome longstanding payment exclusions. Oklahoma now has the authority
to receive federal Medicaid payment for medically necessary residential SMI, SED and/or SUD treatment in IMDs, and Maine has the

authority to receive federal Medicaid payment for SUD treatment in IMDs. [FN123]
We discuss IMD waivers more fully in the following section.

Vil. BEHAVIORAL HEALTH

While the definition of the term 'behavioral health' has changed over time, it is now widely used to encompasses mental health

and substance use disorder (drugs or alcohol), among other things. IFN124] Medicaid is the single largest payer of mental health
services, and the program is an increasingly larger payer for substance use disorder services. [FN125] Some mental health services
are mandatory, but many are optional. [FN126] As an essential benefit, mental health and addiction services are required for the newly
eligible in states that implement the Medicaid expansion, but only 39 states, including the District of Columbia, have done so. [FN127]

The pandemic has exacerbated the problems with mental health and substance abuse, and CMS hoping that mobile crisis intervention
units will help. In September 2021, CMS announced that it awarded $15 million in planning grants to 20 states for Medicaid mobile
crisis intervention services. These units provide around-the-clock services 365 days per year for individuals in crisis due to mental
health or substance abuse problems. CMS believes that these services could save lives and avoid unnecessary incarceration of people
in crisis. In announcing the funds, HHS Secretary Xavier Becerra noted that the pandemic has detrimentally affected mental and
behavioral health, particularly in underserved communities:

'The pandemic has taken a serious toll on the mental health of Americans, especially in underserved communities . . . . Through these
awards, the Biden-Harris Administration is making a bold investment to highlight the importance of behavioral health and ensure states
can provide vital services to those hardest hit by the pandemic. This funding from the American Rescue Plan will expand access to

crisis care for everyone-and reach people where they are." IFN128]
The grants may be used for a variety of purposes:

The planning grants provide funding to develop, prepare for, and implement qualifying community-based mobile crisis intervention
services under the Medicaid program. Grant funds can be used to support states' assessments of their current services; strengthen
capacity and information systems; ensure that services can be accessed 24 hours a day, every day of the year; provide behavioral
health care training for multi-disciplinary teams; or seek technical assistance to develop State Plan Amendments (SPAs), demonstration

applications, and waiver program requests under the Medicaid program. [FN129]

The funds, which are provided through the American Rescue Plan (P.L. 117-2), run for one year. Beginning on April 1, 2022, states will
be temporarily eligible for an enhanced federal match rate for mobile crisis intervention services; funds for the enhanced match rates

are also American Rescue Plan funds. '"N"°°l please see CMS' press release for a link to the list of the 20 states that will be receiving
the funds.

Substance Use Disorder

One huge concern in the area of behavioral health is the opioid abuse crisis. Deaths from overdose doubled from 2007 to 2017; in
2017, 47,600 individuals died from overdose. IFN131] The pandemic exacerbated the problem. According to the CDC, in the 12 months

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preceding April 2021, over 100,000 American died of an overdose, an increase of about 28% over the previous year. [FN132] According

to the Kaiser Family Foundation, Medicaid and CHIP cover about 40% of individuals with an opioid addiction. IFN133) 1 blog post,
CMS explained why it is so concerned about this epidemic: the drugs can cause fatal harm to the central nervous and respiratory
systems; opioid misuse can lead to other drug addictions and hence illnesses such as Hepatitis C and HIV, which are common among
intravenous drug users; accidental overdose is not uncommon; and the number of prescriptions for opioid drugs has quadrupled in less

than 20 years, even though people are not reporting more pain than they were 20 years ago. [FN134]
In 2020, CMS published its CMS Roadmap, Strategy to Fight the Opioid Crisis. It has three focus areas:
Prevention ? managing pain with a range of different solutions that rely less on prescription opioids

Treatment ? expanding access to opioid use disorder services

Data ? leveraging data to target prevention and treatment services and to identify fraud and abuse [FN135]

The Medicaid exclusion for services provided in an 'institution for mental diseases' with over 16 beds has been a stumbling block to
treatment for substance use disorder. The exclusion is a vestige of the original Medicaid law in 1965 that was meant to encourage
treatment in smaller, community-based settings instead of large inpatient institutions. However, it has taken away an important option in

the fight against opioid abuse. [FN136] Policymakers have been battling for several years to change the provision in order to open up this

option. In the meantime, the federal government has been granting waivers to states to develop pilot programs for inpatient substance

abuse treatment at facilities with more than 16 beds, and several states are offering, or are seeking to offer such programs. [FN137]

California is one such state, and officials there see it as a game-changer. [FN138] The final Medicaid managed care rule made a limited
exception to the exclusion, but some see it as inadequate. (Please see 'Medicaid Managed Care,' below.)The IMD exclusion has also
been addressed in CMS' new policy on substance use disorder, as we discuss below.

Section 5052 of the SUPPORT for Patients and Communities Act (P.L. 115-271) also created a limited exception to the IMD exclusion.
CMS released a State Medicaid Director Letter offering guidance to states that wish to implement this new State Plan option. Section
5052 enacted a new section of the Social Security Act, Section 1915(I), which createdan exception to allow states, at their option, to
cover IMD services from October 1, 2019 to September 30, 2023, for individuals aged 19-64 with at least one substance use disorder

diagnosis. Among other things, the letter specifically defines which individuals and IMDs are eligible under the exception. [FN139]

CMS and the Substance Abuse & Mental Health Services Administration (SAMHSA) administer the Certified Community Behavioral
Health Clinic Demonstration, which was meant to increase access to behavioral health and substance use disorder services for
Medicaid and CHIP participants:

This demonstration is part of a comprehensive effort to integrate behavioral health with physical health care, increase consistent use of
evidence-based practices, and improve access to high quality care for people with mental health and substance use disorders. [FN140]
After an initial planning phase in which health clinics were certified, the agencies selected eight states (Minnesota, Missouri, New
York, New Jersey, Nevada, Oklahoma, Oregon, and Pennsylvania) to participate in the demonstration. IFN141] They later announced

that Kentucky and Michigan will be participating as well. IFN142]
Implementing the SUPPORT Act

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act

(P.L. 115-271), which was enacted in 2018, is a comprehensive, multifocal plan to combat the country's opioid crisis. [FN143] it directed
various departments to take specific actions to further the plan. In its first step toward complying with the act, CMS committed up to $50
million in planning grants for states that are interested in finding innovative ways to increase provider capacity for treating substance
use disorder. In a press release, CMS described how it intended for the funds to be used:

The planning grants are intended to increase the capacity of Medicaid providers to deliver SUD treatment or recovery services through
an ongoing assessment of the SUD treatment needs of the State; recruitment, training, and technical assistance for Medicaid providers
that offer SUD treatment or recovery services; and improved reimbursement for and expansion of the number or treatment capacity of

Medicaid providers. [FN144]

State Medicaid agencies were invited to apply with a description of their 18-month proposal for delivering substance use disorder
treatment and recovery services. Later that year, CMS announced that it awarded planning grants to the District of Columbia and 14
states, including Alabama, Connecticut, Delaware, Illinois, Indiana, Kentucky, Maine, Michigan, Nevada, New Mexico, Rhode
Island, Virginia, Washington, and West Virginia. Five of these states were to be selected to implement 36-month demonstrations.

[FN148] CMS later announced that it selected the five states for the demonstration. They are Connecticut, Delaware, Illinois, Nevada,
and West Virginia. IFN146] These states will receive 80% federal matching funds for substance use disorder services that exceed their
2018 expenditures for these services. [FN147]

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Section 8081 of the SUPPORT Act directed HHS to issue guidance to states on providing substance use disorder treatment in family-

focused residential treatment programs, as defined by the act. [FN148] CMS and the Administration for Children and Families (ACF) did
release guidance for the states in accordance with that section. The guidance covers these topics:

Existing opportunities and flexibilities under the Medicaid program, including waivers authorized under section 1115 or 1915 of the Act,
for states to receive federal Medicaid funding for the provision of SUD treatment for pregnant and postpartum women, parents and
guardians and, to the extent applicable, their children, in family-focused residential treatment programs.

How states can employ and coordinate funding provided under the Medicaid program, the title IV-E program, and other HHS programs,
such as the Substance Abuse and Mental Health Services Administration (SAMHSA) grant programs targeting pregnant and
postpartum women, to support the provision of treatment and services provided by a family-focused residential treatment facility.

How states can employ and coordinate funding provided under the Medicaid program and the title IV?E foster care program to
support placing children with their parents in family-focused residential treatment programs. This would include title IV-E foster care
maintenance payments (FCMPs) for a child placed with a parent who is receiving SUD treatment services in a licensed residential

family-based treatment facility for substance abuse pursuant to the FFPSA. [Citations omitted. [FN149]

In accordance with Section 1006(a)(2) of the SUPPORT Act, CMS also released guidance on best practices for designing and
implementing SUD-focused health homes. The guidance is informed by the experiences of the five states that have such a program:

Maine, Maryland, Michigan, Rhode Island, and Vermont. [FN150]

The act also extended the 90% FMAP (federal medical assistance percentage, or match rate) for certain health homes for individuals

suffering with a substance use disorder. A 2019 CMCS [FN151] Informational Bulletin advises states on how they can request this
extended enhanced funding. CMCS also explains the circumstances under which the funds are available:

The extension of the enhanced FMAP pericd is available only for expenditures for the provision of health home services to 'SUD-
eligible individuals" under a 'SUD-focused state plan amendment" (both terms are defined by the statute) that was approved by the
Secretary on or after October 1, 2018. States whose health homes meet those criteria may request that the Secretary extend the
enhanced FMAP period beyond the first 8 fiscal year quarters, for the subsequent 2 fiscal year quarters, for a total of 10 fiscal year
quarters from the effective date of the state plan amendment. States interested in this opportunity should submit a proposal for a new

SUD-focused health home state plan amendment along with a letter of request for an extension of the period of enhanced FMAP.
[FN152]

New reporting requirements accompany the enhanced funds. The Informational Bulletin also includes FAQs.

The SUPPORT Act made medication assisted treatment (MAT) a mandatory benefit. CMS reminded states that this provision was
effective on October 1, 2020, and it explained more about the requirement on Medicaid.gov:

CMS interprets sections 1905(a)(29) and 1905(ee) of the [SUPPORT] Act to require that, as of October 1, 2020, states must include as
part of the new MAT mandatory benefit all forms of drugs and biologicals that the Food and Drug Administration (FDA) has approved
or licensed for MAT to treat OUD. More specifically, under the new mandatory MAT benefit, states are required to cover such FDA
approved or licensed drugs and biologicals used for indications for MAT to treat OUD. States currently cover many of these MAT drugs
and biologicals (for all medically-accepted indications) under the optional benefit for prescribed drugs described at section 1905(a)(12)

of the Act. [FN193)

Further, 2019 FD H.B. 8337 (NS), which became law on October 1, 2020, clarifies that MAT drugs used pursuant to the mandatory
benefit are considered prescribed drugs and covered outpatient drugs subject to section 1927 of the Act. [FN154]

Mental Health

In November 2018, CMS announced an opportunity for states to participate in a new demonstration program for adults with a serious
mental illness (SMI) or children with a serious emotional disturbance (SED); this demonstration also tests a limited exception to the IMD
exclusion. CMS described the opportunity in a State Medicaid Director Letter:

This SMI/SED demonstration opportunity will allow states, upon CMS approval of their demonstrations, to receive [federal financial
participation] for services furnished to Medicaid beneficiaries during short term stays for acute care in psychiatric hospitals or residential
treatment settings that qualify as IMDs if those states are also taking action, through these demonstrations, to ensure good quality

of care in IMDs and to improve access to community-based services as described below. This SMI/SED demonstration opportunity

is comparable to the recent section 1115(a) demonstration opportunity to improve treatment for [substance use disorders], including
opioid use disorder (OUD). However, through these demonstrations, states will focus on demonstrating improved care for individuals
with serious mental health conditions in inpatient or residential settings that qualify as IMDs as well as through improvements to

community-based mental health care. [FN155]

CMS announced that it approved such a demonstration program submitted by the District of Columbia. At the same time, CMS
approved the district's plan to implement a similar demonstration for individuals diagnosed with a substance use disorder. According to
CMS's press release, the district has been particularly affected by the opioid crisis and has experienced a 236% increase in fatal opioid-

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related overdoses from 2014 to 2017. Often, individuals with a substance use disorder also suffer from a serious mental illness, so

CMS and the district see the potential for saving thousands of lives. [FN156] According to the Kaiser Family Foundation, as of November
19, 2021, the District of Columbia and six states (Idaho, Indiana, Oklahoma, Utah, Vermont, and Washington) have SMI/SED
waivers, and seven states (Alabama, Arizona, Maryland, Massachusetts, Montana, New Hampshire, New Mexico, and Vermont)

have such a waiver pending. [FN197]
Vill. HOME- AND COMMUNITY-BASED SERVICES

The goal of home- and community-based services (HCBS) is to allow those with physical or cognitive limitations to remain at home
instead of moving into institutional care. The term includes a wide range of services to meet medical needs (such as home health,
durable medical equipment, personal care, etc.) and social needs (such as adult daycare, home-delivered meals, home assessments,

and so forth). [FN158] For the most part, HCBS are optional benefits in Medicaid, [FN159] though home health services are mandatory.
[FN160] states offer optional benefits either through the State Plan or through Section 1915 or Section 1115 waivers. IFN161] Most people

receive HCBS through optional authorities. [FN162] The Affordable Care Act emphasizes HCBS for Medicaid participants, including the
elderly and persons with physical or cognitive disabilities or mental illness. In 2013, the government reached the point where it is now

spending more on HCBS than on institutional care. IFN163] The preference for home- and community-based services is also evident in
the increasing number of states that are expanding the number of people they serve in the community. According to the Kaiser Family
Foundation's annual budget survey for fiscal years 2019 and 2020, 48 states in 2019 and 47 in 2020 were employing one or more

strategies to increase the number of Medicaid participants served in a home or community setting. [FN164]

While HCBS are optional, nearly all states offer them, [FN165] but the offerings vary widely by state. [FN166] Some decry an 'institutional

bias": While nursing home care is a mandatory benefit, HCBS are not. [FN167] There is some effort afoot in Congress to make HCBS
mandatory, which would end the so-called institutional bias and offer services to the 850,000 individuals on waiting lists for optional
HCBS. Still in draft form, the HCBS Access Act would do just that. Sponsors, including Representative Debbie Dingell (D-Mich.), sought
comments on the draft in the spring of 2021. Representative Dingell's press release explained why the bill is so important:

The proposal seeks to mandate HCBS in Medicaid to provide critical services, creating national, minimum requirements for home and
community-based services, and make it possible to enhance those services and the long-term care workforce. . . .

Under our current long-term care system, too many people cannot access the care they need in their homes and communities even
though these are the environments where most people prefer to receive care. The patchwork system that currently exists through
Medicaid HCBS waivers, where access to services depends on the state in which you live, undermines the much-needed creation of a

durable system. States have been using a waiver process to provide long-term services and supports for almost forty years. [FN 168]

CMS is seeking to develop a 'meaningful and standardized set" of quality measures for HCBS as a part of its Meaningful Measures
initiative, and it issued a request for information (RFI) on HCBS in September 2020. CMS explained why it is important at this point to
develop these measures:

As the number of older adults and people with disabilities grows, Medicaid will need to play an even larger role in ensuring the
availability of these services over the next several decades. Identifying the best quality measures enables CMS to use this information

for other Medicaid initiatives achieving greater transparency and accountability in the Medicaid program. [FN 169]

The RFI sought public input on specific questions that it spelled out in the document. [FN170]

According to former CMS Administrator Seema Verma, the COVID-19 pandemic highlighted weaknesses in the long-term care (LTC)
system. Verma wrote,

'The COVID-19 crisis has shone a harsh light on the human costs of a long-term care system that relies too heavily on institutional
services like nursing homes. Too often, they are seen as the default option, even for those who may not require round-the-clock
care ... . While nursing homes will always be an important part of a complete care continuum, many elderly individuals and their

families should have access to a more robust set of home care and community-based care options." IFN171]

To help states strengthen and improve home- and community-based services, CMS released a toolkit that contains examples of states'
innovative LTC models and best practices for rebalancing LTC to expand home- and community-based services and depend less on

institutional care. FN172] According to a Fact Sheet, the toolkit provides:
State strategies to increase the share of LTSS provided in community-based settings;
Tools designed to assist states with policy and programmatic strategies;

Case studies of innovative programs and creative ways states are leveraging available federal authorities to transform LTSS systems;
and

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Links to relevant resources, 'FN173]

The toolkit, which is available on Medicaid.gov, FN174] ig arranged in four modules. Module 1 sets out some background on institutional

services and home-and community-based services; Module 2 provides strategies for advancing home-and community-based services;

Module 3 sets out current Medicaid flexibilities for rebalancing long-term care; and Module 4 lays out some of the strategies that states

have used to rebalance their system of long-term care services and supports. [FN175]

CMS released another tool in 2021. CMS announced that it launched a web page [FN176] oy, Medicaid.gov to share information about

states' plans to advance innovation in HCBS. The Biden Administration believes that such a hub is especially useful now, as states
begin to think about expanding and improving their HCBS programs with additional funds received through the American Rescue Plan
(P.L. 117-2). That act provided states with a temporary increase of 10 percentage points in their federal medical assistance percentage
(FMAP) for HCBS. In a press release, CMS explained,

To encourage states to expand home and community-based services and strengthen their programs, the Biden-Harris Administration
implemented a funding increase established by the ARP. The ARP provided states with a temporary 10 percentage point increase in
federal Medicaid funding for certain Medicaid home and community-based services from April 1, 2021 through March 31, 2022, if they
meet certain requirements. As the COVID-19 pandemic continues, the additional federal funding made available under the ARP allows
those enrolled in Medicaid who need long-term services and supports to receive the assistance required to reside in the setting of their

choice, 'FN1771

At the same time, CMS announced that it has approved a new Section 1115 waiver for Alabama, which will work concurrently with an
existing Section 1915(c) waiver. Together, the waivers will allow the state to expand HCBS and move individuals off waiting lists. Of the
Alabama waiver, CMS wrote,

The state will now be able to redesign its home and community-based services delivery system to address concerns, such as long
waiting lists, high use of residential services and out-of-home placements, and low integrated community employment rates among its

residents. CMS will also provide the authority needed for Alabama to create a new program that supports individuals with intellectual

disabilities who choose to work, live with family, or live independently. [FN178]

To be eligible for reimbursement under Sections 1915(c), 1915(i), and 1915(k), HCBS must be offered in a community-based, non-
institutional setting. In 2014, CMS released its HCBS Settings rule, which set out the requirements for appropriate HCBS settings. Such
settings include these features, generally:

The setting is integrated in and supports full access to the greater community;
Is selected by the individual from among setting options;
Ensures individual rights of privacy, dignity and respect, and freedom from coercion and restraint;

Optimizes autonomy and independence in making life choices; and

Facilitates choice regarding services and who provides them. [FN179]

The final rule 18°! for HCBS required states to submit a transition plan to CMS demonstrating that they brought existing HCBS
settings into compliance with the final rule. CMS recognized at that time that the transition would be complex, so it gave states five
years to do so. The original due date was March 17, 2019. In an Informational Bulletin, CMS announced that it would extend the

deadline for another three years, until March 16, 2022. IFN181] CMS then realized that, due to the COVID-19 pandemic, states may need
additional time to fully implement the rule. In a State Medicaid Director Letter, CMS spelled out some of the problems states may be
experiencing during the pandemic:

As states are responding to the Coronavirus Disease 2019 public health emergency (COVID-19 PHE), CMS recognizes that its impact
has necessitated changes to states' ongoing efforts to comply with the HCBS settings criteria. States' stay-at-home and/or safer-at-
home orders and the process of social distancing have made it difficult, if not impossible, for states to accurately evaluate how an
individual is experiencing community integration in current HCBS settings. These necessary directives have seriously impacted not only
the measurement of community integration for individuals, but the intent of the Settings Rule to ensure that individuals with disabilities
and older adults have the opportunity to be active participants in their communities. Lastly, older adults and individuals with disabilities
who receive Medicaid HCBS often have underlying conditions that increase risks to health and welfare associated with COVID-19 that

can further delay a return to integrated activities as they existed prior to the global pandemic. [FN182]
Because of these difficulties, CMS indicated that it will give states an additional year, until March 2023, to fully comply with the rule.

In a CMCS Informational Bulletin, CMS advised that the Consolidated Appropriations Act, 2021, extended the Affordable Care Act's
spousal impoverishment provisions for the community spouse of an individual eligible for home- and community-based services.

The Affordable Care Act created these provisions, but they were set to expire in 2018. Subsequent legislation has extended these
provisions several times, the latest being the Consolidated Appropriations Act, 2021, which extended them until September 30, 2023.
The bulletin explains,

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Similar to previous temporary extensions of the ACA's spousal impoverishment-related provision, section 205(b) of the Consolidated
Appropriations Act, 2021 includes a Rule of Construction that addresses how states may apply income and resource disregards
authorized under section 1902(r)(2) of the Act to certain individuals eligible for HCBS. The Rule of Construction enables states to
target less restrictive financial methodologies at individuals eligible for HCBS, including married individuals whose financial eligibility is

determined under the spousal impoverishment rules. CMS expects to provide additional guidance on this matter. [FN183]

A House Bill would make these provisions permanent. [FN184]

The American Rescue Plan (P.L. 117-2) provided for a temporary ten-percentage point increase in the federal medical assistance
percentage (FMAP) for certain HCBS during the COVID-19 emergency period. CMS has now provided guidance for states on
implementing that provision. The bulk of the guidance, which takes the form of a State Medicaid Director Letter, focuses on how to
qualify for and claim the additional federal funds. It addresses these areas:

eligible services;

program requirements;

ways to enhance, expand, or strengthen HCBS;

how to report on activities that enhance, expand, or strengthen HCBS; and
how to claim the increased funding.

Please see the guidance for further details about this new opportunity. [FN185]

Children with special needs rely on home- and community-based services and Medicaid is the largest payer for these services.
According to the authors of an Issue Brief from the Kaiser Family Foundation, the pandemic is disproportionately affecting individuals
with disabilities, including children with special needs. The purpose of the brief is to provide context for continuing discussions about the
need to invest in and support HCBS. In short, the brief concludes that, though children with Medicaid have high needs, Medicaid HCBS,
when available, do a good job of serving those needs. Among the key findings are these:

While families of Medicaid/CHIP-only children with special health care needs are more likely to face financial difficulty, they find their
health care more affordable than those with private insurance only due to Medicaid's cost-sharing protections.

Even though children with special health care needs covered by Medicaid/CHIP-only have greater health care needs, they are more
likely than those with private insurance alone to report that their benefits are always adequate to meet their needs, allow them to see

needed providers, and meet their behavioral health needs, reflecting Medicaid's robust benefit package. [FN186]

These are important considerations when discussing the need to strengthen and support the long-term care system. The American
Rescue Plan provided a temporary ten percentage point increase in the federal medical assistance percentage (FMAP) for HCBS. The
increase is to be applied from April 1, 2021, to March 31, 2022, for states that wish to expand HCBS beyond what was available in

their Medicaid programs as of April 1, 2021. IFN187] Whether states can continue with these services and supports when the temporary
increased FMAP ends is unclear. Additionally, many states took emergency action to support long-term care during the COVID-19

public health emergency, but again, it is unclear whether states can afford to make these changes permanent once the public health

emergency ends. [FN188]

There seems to be widespread agreement that the long-term care system needs to be strengthened, but no clear federal commitment
has been made yet for the required funding. As the authors note,

Although President Biden earlier this year proposed a $400 billion federal investment over 10 years to expand access to Medicaid
HCBS and strengthen the direct care workforce, it is unclear how much of that funding increase will be approved by Congress as it
considers competing priorities in the budget package and calls among some to reduce the overall spending level. The reconciliation
bill being considered by the House includes $190 billion for HCBS. Increased federal funding for Medicaid HCBS beyond the current
1-year could enable states to support the HCBS provider workforce, offer new or expanded HCBS benefits, and/or serve more HCBS

enrollees, all of which can benefit children with special health care needs. [FN189]

Please see the brief for a much more detailed explanation of the matter and some thoughts for the future. [FN190]

CMS has offered states the opportunity to implement some federally-developed HCBS programs. One such program is the Community
First Choice Option (CFC), which can be approved as a Section 1915 waiver. Under the Affordable Care Act, states choosing this
option receive a 6% bump in their Medicaid federal matching funds to design programs that provide community-based attendant

services and supports to those who would otherwise be institutionalized. [FN191] Services that fall under the CFC program include such
things as attendant services to help with daily living activities (e.g., eating, toileting, grooming, dressing, and bathing), instrumental
activities of daily living (e.g., meal preparation, managing finances, and transportation); and health-related tasks, (e.g., catheterization,
range of motion exercises, and medication administration). Other personal services, plus the cost of moving patients back into the

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community from an institution, may also be covered. [FN192] Currently, only five states have an approved State Plan Amendment for a
CFC program. [FN193]

PACE is both a Medicare and Medicaid program. To be eligible, one must be 55 or older, live in the service area of a PACE
organization, be eligible for nursing home care, and be able to live safely in the community instead of in a nursing facility. PACE is an
optional Medicaid benefit, and not every state offers it. [FN194] According to Medicaid.gov, PACE,

provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are

dually eligible for Medicare and Medicaid benefits . An interdisciplinary team of health professionals provides PACE participants with
coordinated care. For most participants, the comprehensive service package enables them to remain in the community rather than
receive care in a nursing home. Financing for the program is capped, which allows providers to deliver all services participants need

rather than only those reimbursable under Medicare and Medicaid fee-for-service plans. PACE is a program under Medicare, and
states can elect to provide PACE services to Medicaid beneficiaries as an optional Medicaid benefit. The PACE program becomes the

sole source of Medicaid and Medicare benefits for PACE participants. [FN195]
CMS published a final rule in 2019 that updated PACE by:

Strengthening protections and improving care for PACE participants; and

Providing administrative flexibility and regulatory relief for PACE organizations [FN196]

The final rule is published at 84 F.R. 25610-01 (June 3, 2019).

Another program, called Money Follows the Person, helps people transition from institutions to home- and community-based settings.
The program was set to expire several years ago but has continually been extended. Most recently, the Consolidated Appropriations

Act, 2021 extended the program through September 30, 2021. [FN197] Currently, nearly all states administer an MFP demonstration, and
HHS has announced that it will grant supplemental funds to those states for planning and capacity building. The government explains
more about the funds on Medicaid.gov:

Under this supplemental funding opportunity, up to $5 million in MFP grant funds is being made available to each eligible state for
planning and capacity building activities to accelerate LTSS [long-term services and supports] system transformation design and
implementation and to expand HCBS capacity. This funding is expected to strengthen the focus and attention on LTSS rebalancing
among states participating in the MFP demonstration and to support MFP grantees with making meaningful progress with LTSS

rebalancing. [FN198]
States were invited to apply for the funds through June 30, 2021.

IX. CARE FOR THOSE WITH COMPLEX NEEDS

The government is keen on integrating care and aligning incentives and payments for the so-called dual eligibles ? those who are

eligible for both Medicare and Medicaid. Approximately 12 million individuals fall into this category. IFN199] CMS explains that some of
these people qualify first for Medicare based on their age or disability and then additionally qualify for Medicaid based on their income.
The opposite may be true as well. Of all dual eligibles, only 10% are receiving care in a program that integrates services between
Medicare and Medicaid. Others must navigate the murky waters between two programs that have different benefits, services, and
payment structures. CMS believes that better aligning the two programs could improve care for this population and save federal health

care dollars. "°°! cms has always been concerned about this population because they tend to be sicker and suffer from multiple
chronic illnesses:

Forty-one percent of dually eligible individuals have at least one mental health diagnosis, 49 percent receive long-term care services
and supports (LTSS), and 60 percent have multiple chronic conditions. Eighteen percent of dually eligible individuals report that they

have 'poor' health status, compared to six percent of other Medicare beneficiaries. [FN201]

Because of their poor health, dual eligible have historically been disproportionate users of federal health care funds. According to CMS,
dually eligible individuals account for 20% of all Medicare participants but require 34% percent of all Medicare spending. In Medicaid,

dually eligible individuals account for 15% Medicaid participants and 33% of Medicaid spending. [FN202]

CMS is hoping to provide better, less costly care to these individuals through several initiatives, including the Medicare-Medicaid
Financial Alignment Initiative. In this program, the federal government partners with states to integrate care for these patients and align
Medicare and Medicaid payments and incentives. The initiative uses two models:

Capitated Model: A State, CMS, and a health plan enter into a three-way contract, and the plan receives a prospective blended
payment to provide comprehensive, coordinated care.

Managed Fee-for-Service Model: A State and CMS enter into an agreement by which the State would be eligible to benefit from savings
resulting from initiatives designed to improve quality and reduce costs for both Medicare and Medicaid. [FN203]

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According to the initiative's web page, thirteen states are participating. CMS has released multiple reports from various states. Please
see the initiative's web page for more information. [FN204]

In 2018, CMS issued a State Medicaid Director Letter that outlines ten opportunities for states to better care for dual eligibles, none of
which, according to CMS, requires complex demonstrations or waivers. These include:

State contracting with D-SNPs [dual eligible special needs plans]

Default enrollment into a D-SNP

Passive enrollment to preserve continuity of integrated care

Integrating care through PACE [Programs for All-inclusive Care for the Elderly]

Reducing the administrative burden in accessing Medicare data for use in care coordination
Program integrity opportunities

MMA [Medicare Prescription Drug, Improvement and Modernization Act] file timing

State buy-in file data exchange

Improving Medicare Part A buy-in

Opportunities to simplify eligibility and enrollment [FN205]

CMS explained more fully about each opportunity in the State Medicaid Director Letter.

In a 2019 State Medicaid Director Letter, CMS informed states about new and existing opportunities to improve care for dual eligibles

by better aligning the two programs and integrating care. IFN206] Two of these models already exist. They are the capitated financial
alignment model and the managed fee-for-service model, both of which are a part of the Medicare-Medicaid Financial Alignment
Initiative, but CMS is willing to make revisions to the program to better suit both existing and new participants. CMS also offered a third
opportunity, which would allow states to design their own models. The agency gave some guidance on what it would like to see in these
new designs:

States could consider approaches broadly applicable to all dually eligible individuals or focus on certain segments of the population,
such as people using LTSS, younger people with disabilities, and/or people living in rural areas. These approaches could build off
elements from the FAI [Financial Alignment Initiative] demonstrations or other types of delivery system reforms including alternative
payment methodologies, value-based purchasing, or episode-based bundled payments. An important priority for the Innovation Center

and across CMS is addressing social determinants of health. [FN207]

The later State Medicaid Director Letter complements CMS' December 2018 letter, which reminded states about existing opportunities
for better caring for dual eligibles, "708

X. MEDICAID AND SOCIAL SUPPORTS

In many respects, social needs are related to medical needs. People have to prioritize their concerns, and if they have no home, they
are unlikely to follow a medication regimen, for example. Some make a distinction between social needs and social determinants
of health, arguing that addressing someone's social needs is helpful only to that particular person's health, while addressing social

determinants of health means making systemic changes to improve way people live. [FN209] Authors in a Health Affairs Blog post argue
that conflating the two may impede efforts to actually make a difference on social determinants of health:

[The referenced articles on social determinants of health] aren't about improving the underlying social and economic conditions in
communities to foster improved health for all ? they're about mediating patients' individual social needs. If this is what addressing the
social determinants of health has come to mean, not only has the definition changed, but it has changed in ways that may impede

efforts to address those conditions that impact the overall health of our country. [FN210]

The authors' observations are well-taken and thoughtful; however, policymakers, writers, and advocates have not widely made a
distinction. For purposes of this discussion, we will use the terms that our sources use.

Citing the World Health Organization, the Kaiser Family Foundation sets out these factors as social determinants of health:
Economic stability (employment, income, debt, bills, etc.)

Neighborhood and physical environment (safety, housing, transportation, recreation, walkability, etc.)

Education (literacy, language, level of education)

Food (hunger and access to decent food)

Community and social context (social integration, support, involvement in the community, discrimination, etc.)

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Health care system (coverage, access to providers, the level of the provider's cultural competence, etc.) [FN211]

Experts see a need to rebalance spending on clinical needs and social needs. According to some experts, the United States spends
more of its GDP on medical needs than most other developed countries but does not experience better health outcomes (and
sometimes experiences worse outcomes). On the other hand, our spending on other social services is considerably less than other

developed countries. IFN212] The question is how to effectively add health-related social supports to programs like Medicaid. The
Commonwealth Fund has released a brief describing various ways that states can enable Medicaid managed care organizations and
their providers to offer health-related social supports. The organization offers six strategies, and it discusses at length the pros and cons
of each:

We identify the following options: 1) classify certain social services as covered benefits under the state's Medicaid plan; 2) explore the
additional flexibility afforded states through Section 1115 waivers; 3) use value-based payments to support provider investment in social
interventions; 4) use incentives and withholds to encourage plan investment in social interventions; 5) integrate efforts to address social

issues into quality improvement activities; and 6) reward plans through higher rates for effective investments in social interventions.
[FN213]

The brief also includes brief descriptions of strategies used in Arizona and Oregon.

Several initiatives are afoot to address social determinants of health, and the Kaiser Family Foundation mentions several Medicaid
initiatives that do so: the State Innovation Model Initiative, Section 1115 waivers, Delivery System Reform Incentive Payment (DSRIP)
initiatives, health homes, housing supports through an optional State Plan authority or a waiver, Medicaid managed care, and voluntary

supported employment assistance through various authorities. [FN214]

Finally, the Commonwealth Fund has worked with other health policy leaders to release 'The Evolving Roadmap to Address Social
Determinants of Health," which is an extensive library of tools, resources, guidance, and best practices. Many of the resources focus on
Medicaid's potential for addressing social problems, lessons learned from Medicaid initiatives, and so forth. The roadmap focuses on
six areas that are deemed to be 'drivers" for successfully addressing social needs in clinical settings. These drivers are:

patient identification and screening;
navigation and resource connections;
social health team and workflow;
data and evaluation

community partnerships;

leadership and change management IFN215]

On the state level, CMS approved North Carolina's Section 1115 waiver for its Health Opportunities pilot program in 2018. The waiver
allows the state to provide case management and other services to address social determinants of health, such as 'socioeconomic
status, education, neighborhood and physical environment, employment, nutrition/food security, and social support networks, as well

as access to health care." "N2"6l To be eligible, a person must be enrolled in managed care and must exhibit at least one physical or
behavioral health risk factor and at least one social risk factor. The program, which has not yet begun, will be implemented in two to
four regions of the state, and officials estimate that 25,000 to 50,000 Medicaid participants will benefit from the program.

The brief describes some of the services that the pilot will offer:

Pilot services will include evidence-based enhanced case management and other services designed to address enrollee
needs related to: housing, food, transportation, and interpersonal safety.For example, pilot services may include housing
modifications (e.g., carpet replacement, air conditioner repair) to improve a child's asthma control, travel vouchers to a
community-based food pantry or a medically-targeted healthy food box for an adult with diabetes living in a rural food desert,
or assistance securing safe housing for a pregnant woman experiencing interpersonal violence. The care manager will
recommend pilot services at the lowest intensity level that can be reasonably expected to meet an individual's needs. Pilot
transportation services include non-emergency health-related transportation including transportation to social services or to
access pilot services. (Transportation services under the pilot are in addition to the non-emergency medical transportation
(NEMT) benefit states are required to provide which helps ensure Medicaid beneficiaries have transportation to and from

medical providers.) [FN217]

The authors pointed out that this waiver differs a bit from the types of waivers that CMS has typically approved in the last couple

of years. CMS' new direction in waiver approval has been favoring work and community engagement requirements and reporting
requirements, while North Carolina's pilot is aimed at ameliorating the causes of health disparities and poor health. The authors write of
CMS' new waiver policies, which favor work requirements and reporting,

In its approval of these demonstrations, the administration asserts such policies are designed to address health determinants (like
employment) and to ultimately improve health outcomes. These new waivers run counter to many other efforts to address social

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determinants of health that focus on identifying social needs and facilitating links to services rather than making individuals' health
coverage dependent on meeting certain requirements ? like reporting minimum monthly work hours. [FN218]
Please see the brief for a fuller discussion of the program.

Finally, In a State Health Official Letter, CMS gave guidance to the states about existing opportunities to address social determinants
of health through Medicaid services. The letter had three areas of focus: (1) describing general principles to which states must adhere
when offering services and supports addressing social determinants of health, (2) commonly-offered Medicaid services and supports

that address social determinants of health, and (3) federal authorities that states can use to offer such services and supports. [FN219]
One of the overarching principles that states must keep in mind is that these types of services and supports must be offered based on
individual needs and not on a 'one-size-fits-all" basis. Services that can be covered under Medicaid include:

Housing services and supports
Non-medical transportation
Home-delivered meals
Educational services
Employment services

Community Integration and social support services

Case management services [FN220]

CMS also outlined some of the authorities on which states can rely in offering services, including State Plan authority, home- and
community-based services options under Section 1915, demonstration authority under Section 1115, Section 1945 health homes,
managed care, and PACE (Programs of All-Inclusive Care for the Elderly), among others. Please see the letter for more details on all of
these options.

XI. MATERNAL HEALTH

The federal government and the states are taking steps to expand coverage of postpartum care. Currently, states are only required

to provide 60 days of post-partum coverage to women earning up to 138% of the federal poverty level, [FN221] but many states have
moved to extend this coverage to one year either by seeking a waiver from CMS or by using state-only funds. HPTS has previously

reported on the many bills at both the state and federal level seeking to accomplish this. [FN222] Taking a big leap in this direction, the
American Rescue Plan offered states the option of providing, with federal financial support, post-partum coverage for one year after

childbirth. Currently, the option is available for five years, starting April 1, 2022. [FN223] Georgetown University Health Policy Institute has
advice for federal and state officials on what they can do now to ensure that they are ready when the option becomes available. [FN224]

Against this backdrop, the HHS Secretary Xavier Becerra announced new actions that his department made in honor of Black Maternal
Health Week. Becerra said that maternal health, and particularly Black maternal health, is one of the Biden Administration's priorities,
and the Secretary's press release revealed why:

Medicaid covers 1 in 5 women of reproductive age and helps make prenatal and delivery care accessible for nearly half of women
giving birth. With a third of maternal deaths occurring between one week to a year after childbirth, and Black women two times more
likely to die from a pregnancy related cause than white women, providing this continued Medicaid coverage helps ensure women not
only recover from birth, but they also have access to the ongoing care they need during and following giving birth. The continuity of
coverage available through this Medicaid amendment can help mothers manage chronic conditions like hypertension and diabetes, and

provide access to behavioral health and other mental health care services. [FN225]

Secretary Becerra also pointed to data showing that one-half of pregnant Medicaid participants experienced a gap in coverage in

the first six months following childbirth, which can lead to a complete loss of coverage and a loss of care. He noted the American
Rescue Plan's provision allowing states to cover post-partum care for one year after childbirth, and he also noted that his agency

has approved Illinois' demonstration providing full coverage for one year post-partum. At the same time, he announced a $12 million
funding opportunity over four years for the Rural Maternity and Obstetrics Management Strategies program. Awardees will test models
that address unmet needs for their target populations, which will include populations that have historically suffered from poorer health

outcomes, health disparities, and other inequities. [FN226]
Drug use among pregnant and postpartum women is another concern for the government. To address this problem, in 2019, CMS
announced funds for initiative that it hopes will help pregnant and post-partum women affected by the opioid crisis. In that one, the

Maternal Opioid Misuse (MOM) model, CMS is promoting the coordination of care and the integration of services for pregnant and post-
partum women with a substance use disorder. CMS explains why this model is needed:

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Despite the significant and costly burden of maternal opioid misuse, numerous barriers impede the delivery of well-coordinated, high-
quality care to pregnant and postpartum women with OUD, including:

¢ Lack of access to comprehensive services during pregnancy and the postpartum period, even though state Medicaid programs
may be able to provide the necessary coverage through state plan amendments or waivers.

¢ Fragmented systems of care, which miss a critical opportunity to effectively treat women with OUD at a time when they may be
especially engaged with the healthcare system.

¢ Shortage of maternity care and substance use treatment providers for pregnant and postpartum women with OUD covered by
Medicaid, especially in rural areas, where the opioid crisis is magnified. [FN227]
MOM will use a variety of strategies to address these shortcomings in the health care system, including:

Fostering coordinated and integrated care delivery: Support the delivery of coordinated and integrated physical health care,
behavioral health care, and critical wrap-around services.

Utilizing Innovation Center authorities and state flexibility: Leverage the use of existing Medicaid flexibility to pay for sustainable care for
the model population.

Strengthening capacity and infrastructure: Invest in institutional and organizational capacity to address key challenges in the
provision of coordinated and integrated care. [FN226]

CMS will enter into cooperative agreements with up to 12 states, which will implement 'care delivery partners" in the community.

[FN229] |, 2019, CMS announced that it awarded funds to ten states, including Colorado, Indiana, Louisiana, Maine, Maryland,
Missouri, New Hampshire, Tennessee, Texas, and West Virginia. The states will share in a total of $50,000,000, which they will use

to transition to the new model and then fully implement it. [FN230] Currently, only nine states are participating.
XII. MANAGED CARE

Managed care has become the most prevalent care delivery model in Medicaid and CHIP (the Children's Health Insurance Program).
CMS cited these statistics:

As of July 2018, 53.9 million individuals were enrolled in Medicaid managed care, which represents 69 percent of the total Medicaid
enrollment.

In fiscal year 2018, total federal and state Medicaid managed care expenditures were $296 billion, which is approximately 50 percent of
total Medicaid expenditures.

In 31 states, about 79 percent of CHIP children were enrolled in managed care.

Twenty-two states had Managed Long-Term Supports and Services (MLTSS) programs in operation as of July 1, 2018. [FN231]

Because the delivery model is so widely used, CMS released an Informational Bulletin that lays out tools that both CMS and the states
can use to monitor and provide oversight of managed care in Medicaid and CHIP. [FN232]

In 2016, the Obama Administration issued a sweeping final rule for Medicaid managed care, the first such update in a decade. Notably,

the rule included provisions to improve access to care and to strengthen consumer protections. [FN233] The 2016 final rule also included
a provision allowing Medicaid managed care programs to pay for inpatient addiction services in Institutions for Mental Disease (IMDs)
with more than 16 beds. The rule does not apply to Medicaid fee-for-service plans, and it only pays for 15 days. Previously, Medicaid

applied an exclusion for these types of services. Given the epidemic of opioid addiction, many lawmakers [FN234] ond health policy
experts believe that the 15-day period is too short and may violate CMS' own Medicaid mental health parity rule. IFN235]

Almost immediately upon taking the helm, the Trump Administration announced plans to release another managed care rule with
major changes, and it released a proposed rule in 2018. The rule was meant to promote flexibility, strengthen accountability, and
promote program integrity. CMS developed the proposed rule after working with state Medicaid directors and the National Association
of Medicaid Directors. According to CMS, it learned from its discussions with stakeholders that they thought that some provisions of
2016 final rule created unnecessary administrative burden and cost without leading to improved outcomes. CMS indicated that the
new proposed rule was meant to 'relieve regulatory burdens; support state flexibility and local leadership; and promote transparency,

flexibility, and innovation in care delivery. " [FN236] Briefly, some of the proposed changes were these:

Promoting flexibility ? giving states more flexibility to establish a rate range; making it easier to transition more services and populations
into managed care; allowing states more flexibility to create their own network adequacy standards; and removing outdated and overly
burdensome rules about how plans communicate with their members.

Strengthening accountability ? requiring CMS to be accountable by providing states more guidance, and maintaining the requirement
for states to develop a quality rating system but allowing states more flexibility to create an alternate system.

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Promoting program integrity - strengthening requirements to protect federal taxpayers from cost shifting. [FN237]

CMS also indicated in its press release that stakeholders expressed concern about the limited exception to the IMD exclusion in the

2016 final rule, IFN238] but the agency proposed no changes in the proposed rule:

[S]tates expressed their concerns with how the 2016 final rule's limitation of 15 days on lengths of stay for managed care beneficiaries
in an institution for mental disease (IMD) created difficult administrative challenges for states. CMS is not proposing any changes to this
requirement at this time; however, it is asking for comment from states for data that could support revisions to this policy. Meanwhile,
CMS continues to support state flexibility through section 1115 demonstrations, having approved a total of 15 waivers of the IMD
exclusion for states to treat patients with substance use disorder (SUD), to expand access to treatment, and is exploring further options

remove barriers to important treatment options. [FN239]

The proposed rule is published at 83 F.R. 57264-01 (Nov. 14, 2018), and CMS provided a summary of the rule's major provisions.
[FN240]

In November 2020, CMS announced the final rule. According to the Kaiser Family Foundation, the proposed rule was finalized with few
changes. The new rule does not completely supplant the 2016 rule, but it makes changes in the areas of network adequacy; beneficiary
protections; quality oversight; and rate-setting and payment. The foundation has published a brief setting out the differences between

the 2016 and the 2020 rules. !FN241]

Finally, the Center for Medicaid and CHIP Services (CMCS) published guidance for states on the Medicaid managed care medical
loss ratio (MLR). The guidance describes MLR requirements in the managed care final rule and explains how those requirements were

temporarily changed by the SUPPORT for Patients and Communities Act (P.L. 115-271), N41
XIV. SELECTED FEDERAL ACTIVITY

The first piece of COVID-related legislation that Congress passed was The Coronavirus Preparedness and Response Supplemental

Appropriations Act, 2020 (P.L. 116-123). While the act allocated funds for health-related programs and for testing and vaccines, [FN243]
it did not have a big impact on Medicaid. Former President Donald Trump (R) signed that bill on March 6, 2020.

Former President Trump signed The Families First Coronavirus Response Act (P.L. 116-127) on March 18, 2020. Among other things,
the bill provides for Medicaid coverage without cost sharing for COVID-19 testing and testing related services. It also includes a 6.2%

increase in states' federal medical assistance percentage (FMAP). IFN244] The increase applies retroactively from January 1, 2020,
and continues until the public health emergency ends. However, states must meet certain requirements to claim the increase, and the

increase does not apply to all expenditures. The government released an FAQ document IFN245] to clarify the requirements for receiving
the increased FMAP. Importantly, the increase does not apply to the already higher FMAP for newly eligible adults in the Medicaid
expansion, nor does it apply in other situations in which a special FMAP is already in place. Additionally, administrative expenses do
not qualify. Notably, in order to qualify for the increase, states must refrain from disenrolling program participants during the emergency
period. The full list of requirements is set out on Medicaid.gov:

To qualify for the temporary FMAP increase, states must, through the end of the month when the public health emergency ends:

a. Maintain eligibility standards, methodologies, or procedures that are no more restrictive than what the state had in place as of
January 1, 2020 (maintenance of effort requirement).

b. Not charge premiums that exceed those that were in place as of January 1, 2020[.]

c. Cover, without impositions of any cost sharing, testing, services and treatments- including vaccines, specialized equipment, and
therapies-related to COVID-19.

d. Not terminate individuals from Medicaid if such individuals were enrolled in the program as of the date of the beginning of the
emergency period, or becomes enrolled during the emergency period, unless the individual voluntarily terminates eligibility or is no
longer a resident of the state (continuous coverage requirement).

These requirements became effective on March 18, 2020. [FN246]
Another provision of the Families First Act allows states, at their option, to create an eligibility group in which uninsured individuals can
get Medicaid coverage for COVID-19 testing. CMS has issued guidance to states interested in taking up this option. [FN247]

On April 13, 2020, CMS issued further guidance for both the Families First Act and a later act (the Coronavirus Aid, Relief and

Economic Security (CARES) Act (P.L. 116-136)), and it corrected an important misstatement in the previously-issued FAQs. [FN248] jy
the earlier guidance, CMS stated that the increased FMAP does not apply in certain situations where a special FMAP already applies,
and it specifically listed the Community First Choice (CFC) program as one of them. In the more recent guidance, CMS clarified that the
new FMAP does in deed apply to expenditures related to CFC:

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We incorrectly stated that the 6.2 percentage point FMAP increase under the FFCRA [Families First Coronavirus Response Act] does
not apply to Community First Choice (CFC) 1915(k) service expenditures, which are already eligible for a separate 6 percentage

point FMAP increase. Expenditures for these services are, in fact, eligible for both the 6 percentage point FMAP increase under
section 1915(k) of the Social Security Act and the 6.2 percentage point increase under section 6004 of the FFCRA, if the expenditures
otherwise qualify. These FMAP increases are additive.

Please see the FAQ document for more details about the increased FMAP.

The Coronavirus Aid, Relief and Economic Security (CARES) Act (P.L. 116-136), includes a number of health-related provisions. The
Kaiser Family Foundation has provided an extensive summary of all of the act's provisions. Those that affect Medicaid include these,
among others:

[FN249]

¢ The act extends the Money Follows the Person program until November 30, 2020, and authorizes additional funds.

¢ The act extends the Medicaid Community Mental Health Services demonstration and directs the HHS Secretary to select two more
states to participate.

« It directs the HHS Secretary to issue guidance about the use of telecommunications systems, including remote monitoring, for home
health services.

¢ It adds to the list of providers who can order home health services in both Medicare and Medicaid.
¢ The act clarifies the definition of 'uninsured individuals" who are eligible for Medicaid-covered testing services under the Families First
Coronavirus Response Act.

¢ It amends the provision in the Families First Act that made COVID-19 testing products a Medicaid-covered lab service and exempted
them from cost-sharing requirements; specifically, the CARES Act removes the requirement that these products be FDA-approved.

¢ It amends the Families First Act provision offering a 6.2% increase in a state's FMAP when certain requirements are met, including
the requirement that a state may not impose premiums higher than those in effect on January 1, 2020; the CARES Act makes a limited
exception to this requirement.

* It extends the Affordable Care Act provision requiring states to apply the Medicaid spousal impoverishment rules for those receiving
institutional long-term care to those receiving home and community-based services.

¢ The act delays the reductions in state Medicaid disproportionate share hospital allotments.

¢ The act clarifies that home- and community-based Medicaid services may be provided in an acute care hospital if they are identified
in the patient's service plan, meet needs that the hospital does not satisfy, do not substitute for services that the hospital is required to

render, and are designed to ease the transition from acute care to home- and community-based services. [FN250]
Please see the foundation's brief for more details.

Former President Trump signed 2019 FD H.B. 266 (NS) on April 24, 2020. '-825"! That bill enacted the Paycheck Protection Program
and Health Care Enhancement Act (the Paycheck Protection Act). The Paycheck Protection Program was established by the CARES
Act (P.L. 116-136). The Paycheck Protection Act makes changes to the CARES Act to afford enhanced relief to businesses affected
by the COVID-19 pandemic. The Paycheck Protection Act also contains health provisions that funnel additional funds to HHS. The
funds are to be used to ameliorate losses that 'eligible health care providers" have suffered due to the pandemic and to support them
as they continue to fight its effects. Medicare and Medicaid providers and suppliers are included in the definition of 'other eligible
providers. "Additionally, the act ensures funding to advance research and testing for the virus. The Kaiser Family Foundation has

published a summary of the act's health-related provisions. "752!

The latest stimulus bill, the American Rescue Plan Act of 2021 (2021 FD H.B. 1319 (NS)), was signed into law by President Joseph
Biden (D) on March 11, 2021. "N255] The bill affects Medicaid in a number of ways. Among other things, the bill would:

* mandate Medicaid coverage of COVID-19 vaccines without cost-sharing with costs fully paid by the federal government;

* mandate coverage without cost sharing for COVID-19 treatment for those in the uninsured testing group established by the Families
First Act and for those who receive Alternative Benefit Plans;

¢ create a state option to extend post-partum coverage for 12 months following the birth of a child;

* temporarily increase the FMAP [FN254] for Medicaid home- and community-based services an additional 10 percentage points when
certain conditions are met;

* temporarily increase the FMAP by 5 percentage points for states that are new adopters of the Medicaid expansion (the newly eligible
are already covered by a 90% FMAP); and

¢ provide additional funds from the Provider Relief Fund for rural Medicaid, CHIP, and Medicare providers. [FN265]

On June 3, 2021, CMS published guidance on some of the Medicaid provisions in the ARP, including:

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* mandatory coverage of COVID-19 vaccines, vaccine administration, testing, and treatment;
¢ the enhanced, temporary FMAP (federal medical assistance percentage) for home- and community-based services;
« the enhanced, temporary FMAP for states that implement the Medicaid expansion;

the recalculation of the disproportionate share hospital allotments for states that claim the enhanced FMAP provided for the in the
Families First Coronavirus Response Act (P.L. 116-127);

¢ the extension of 100% FMAP to Urban Indian Health Organizations and Native Hawaiian Health Care Systems;
¢ the option to provide for certain community-based mobile crisis intervention services under the Medicaid state plan or a waiver;

« the option to provide 12-month coverage for post-partum services; and

¢ removal of the 100% cap for certain drugs under the Medicaid Drug Rebate Program. [FN256]

CMS published a proposed rule affecting the Preadmission Screening and Resident Review. States must have a system to conduct this
type of review for individuals with mental illness or intellectual disability who are residing in or applying to reside in a Medicaid nursing
facility. The review is done to ensure that such individuals are properly placed. The purpose of the rule, which is published at 85 F.R.
9990 (Feb. 20, 2020) is stated in the summary:

This proposed rule would modernize the requirements for Preadmission Screening and Resident Review (PASRR), currently referred
to in regulation as Preadmission Screening and Annual Resident Review, by incorporating statutory changes, reflecting updates to
diagnostic criteria for mental illness and intellectual disability, reducing duplicative requirements and other administrative burdens on
State PASRR programs, and making the process more streamlined and person-centered.

CMS finalized a rule aimed at reining in the price of prescription drugs in the Medicaid program. The rule will provide regulatory support
for states and drug manufacturers to enter into value-based purchasing agreements:

This final rule advances CMS' efforts to support state flexibility to enter value-based purchasing arrangements (VBPs) with drug
manufacturers for innovative, and sometimes costly drugs therapies, and to provide manufacturers with regulatory flexibility to enter into

VBPs with commercial payers, which will benefit Medicaid programs. "N71
The rule advances flexibility by allowing states to make choices based on more information:

Manufacturers that offer VBP arrangements with commercial payers and offer these arrangements to states will be permitted to report
varying best price points, as applicable. States may choose to enter into these arrangements or opt out of them and continue to receive
the traditional Federal Medicaid drug rebate, which would be calculated using the 'best price" in a non-VBP arrangement that the
manufacturer makes available for that drug in the quarter. . . .

To further facilitate VBP arrangements, this final rule defines VBP arrangements as those that include evidence-based and/or
outcomes-based measures; includes VBP arrangements under the definition of 'bundled sale"; and permits manufacturer revisions to
AMP and 'best price" reporting beyond the current twelve-quarter time limit to allow for revisions to pricing metrics as a result of VBP

arrangements. [FN258]

The rule also establishes minimum standards for the states' drug utilization review programs in order to curb fraud or abuse in the
prescribing of opioid drugs. Please see the Fact Sheet for a summary of other provisions in the rule. The final rule is published at 85
F.R. 87000-01 (Dec. 31, 2020). In May 2021, CMS published a rule that propose to delay the effective dates and inclusion dates of
certain provisions. The proposed rule is published at 86 F.R. 28742-01 (May 28, 2021). On November 19, 2021, CMS finalized that
rule, extending effective dates as follows:

This final rule will delay for 6 months the January 1, 2022 effective date for amendatory instruction 10.a., which addresses the reporting
by manufacturers of multiple best prices connected to a value based purchasing (VBP) arrangement, of the final rule entitled, 'Medicaid
Program; Establishing Minimum Standards in Medicaid State Drug Utilization Review (DUR) and Supporting Value-Based Purchasing
(VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements', published in

the December 31, 2020 Federal Register to July 1, 2022. This final rule will also delay for 9 months the April 1, 2022 effective date

of inclusion (hereinafter referred to as the inclusion date) of the U.S. territories (American Samoa, Northern Mariana Islands, Guam,
Puerto Rico, and the Virgin Islands) in the amended regulatory definitions of 'States" and 'United States" for purposes of the Medicaid
Drug Rebate Program (MDRP), adopted in the interim final rule with comment period entitled, 'Medicaid Program; Covered Outpatient
Drug; Further Delay of Inclusion of Territories in Definitions of States and United States", published in the November 25, 2019 Federal

Register to January 1, 2023. [FN259]
In the Senate, 2021 FD S.B. 151 (NS), which would enact the COVID HCBS Relief Act of 2021, would temporarily increase by 10

percentage points state FMAPs IFN260] for home- and community-based services upon approval of an application. The FMAP would
be added to the already increased FMAP set by the Family First Coronavirus Relief Act (P.L. 116-127) and would be effective from
October 1, 2020, to September 30, 2022. The bill defines home- and community-based services as follows:

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(C) Home and community-based services. The term 'home and community-based services' means home health care services
authorized under paragraph (7) of section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)), behavioral health services
authorized under paragraph (13) of such section, personal care services authorized under paragraph (24) of such section, PACE
services authorized under paragraph (26) of such section, services authorized under subsections (b), (c), (i), (j), and (k) of section 1915
of such Act (42 U.S.C. 1396n), such services authorized under a waiver under section 1115 of such Act (42 U.S.C. 1315), and such
other services specified by the Secretary.

The Senate Special Committee on Aging issued a press release about the bill, summarizing how the COVID HCBS Relief Act would
invest in home- and community-based services:

Earlier this year, Senator [Bob] Casey introduced the COVID HCBS Relief Act of 2021, which would provide a 10 percent Federal
Medical Assistance Percentages (FMAP) increase to states to be used to enhance HCBS; funds can be used to support front-line
workers with increased pay, paid sick and family medical leave and personal protective equipment, among other essential supports.
Since March 2020, Senator Casey has also introduced three other bills to invest in HCBS. Seniors and people with disabilities are
uniquely vulnerable to the COVID-19 virus; people with developmental disabilities have died from COVID-19 at a rate of three times

higher than the general population. Currently, more than 800,000 people nationwide are waiting to receive HCBS, with nearly 16,000 in

Pennsylvania. [FN261]

The companion bill in the House is 2021 FD H.B. 525 (NS). In addition to sponsoring the Senate bill, Senator Bob Casey (D-Pa.) and
others sent a letter to President Joseph Biden (D) urging further investment in home- and community-based services as a way to
strengthen the long-term care workforce, particularly for those who choose home or community care over institutional care. As the letter
writers aptly point out, our aging population will require a robust long-term care system, and these investments would help ensure such

a system. Such investments would also bolster the economy, which has been battered by the COVID-19 pandemic. [FN262]

Senate Bill 274 (2021 FD S.B. 274 (NS)) would enact the Stronger Medicaid Response to the COVID-19 Pandemic Act. That act would
allow states, at their option, to provide Medicaid coverage for COVID-19 vaccines and treatment for uninsured individuals. Senator
Michael Bennet (D-Colo.), one of the bill's sponsors, explains what the bill would do:

The Stronger Medicaid Response to the COVID-19 Pandemic Act increases support for expanding health care needs resulting from the
current public health crisis. The legislation would allow Medicaid programs to pay for treatment and prevention, hospitalization, drugs,
vaccines, and other related services for individuals with COVID-19 who are uninsured. This builds on the Families First Coronavirus

Response Act which provided Medicaid coverage for COVID-19 testing for uninsured individuals. [FN263]

Senator Jeanne Shaheen (D-NJ) and others introduced 2021 FD S.B. 274 (NS), which would enact the Stronger Medicaid Response
to the COVID?19 Pandemic Act. Senate Bill 274 would allow states to provide to the uninsured Medicaid coverage without cost-sharing
for COVID-19 prevention and treatment, and for coverage of preventive services and treatment for conditions that may complicate

COVID-19 treatment. The option would be open for the duration of the public health emergency. IFN264] Earlier in the pandemic,
the Families First Coronavirus Response Act gave states the option to offer Medicaid coverage of COVID-19 testing for uninsured

individuals. However, fewer than one-half of the states have taken up the option. IFN265] Since Senator Shaheen's bill was introduced,
Congress passed and President Joseph Biden (D) signed the American Rescue Plan. That bill allows states, at their option, to provide
Medicaid coverage to uninsured individuals for the cost of COVID-19 vaccinations and treatment for COVID-19 for the duration of the
public health emergency. The companion bill in the House is 2019 FD H.B. 918 (NS).

Also in the Senate, 2021 FD S.B. 439 (NS), which was introduced on February 25, 2021, would enact the Coronavirus Medicaid

Response Act. That act would increase state Medicaid FMAPs [FN266] during times of economic downturn. The bill defines 'economic
downturn' in relation to a state's unemployment rate. A press release from Senator Michael Bennet (D-Colo.), one of the bill's sponsors,
explained how the process would work:

This legislation would respond to the increased need for health care during the public health and economic crisis by creating a quicker
and more responsive process for supporting state Medicaid programs. It would address fluctuating demand in states for Medicaid by
automatically connecting the Medicaid Federal Medical Assistance Percentage (FMAP) to state unemployment levels, so that additional

federal aid would ebb and flow with a state's economy. [FN267]
Introduced by Senator Cory Booker (D-NJ) and others, 2021 FD S.B. 346 (NS) would enact the Black Maternal Health Momnibus Act

of 2021. This multifocal bill aims to end preventable maternal mortality and severe morbidity and address racial disparities in maternal
outcomes. As it related to Medicaid, the bill would, among other things:

* call for a task force to address social determinants of health in maternal care. The report of that task force would include
recommendations for expanding social service coverage to address social determinants of maternal health under Medicaid managed
care organizations and State Medicaid programs;

* require HHS to report on maternal health data collection processes and quality measures, including the strengths and weaknesses of
maternal care quality measures in Medicaid;

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¢ require a report from MACPAC on the implications of pregnant and postpartum incarcerated individuals being ineligible for Medicaid
under a State plan;

¢ call for a demonstration project, to be known as the Perinatal Care Alternative Payment Model Demonstration Project, to test payment
models for maternity care under Medicaid State Plans.

Please see the bill for other Medicaid provisions.

If passed 2021 FD S.B. 646 (NS) would provide for 12-month continuous enrollment in Medicaid and the Children's Health Insurance
Program (CHIP). The bill is sponsored by Senators Sherrod Brown (D-Ohio), Tammy Baldwin (D-Wis.), Elizabeth Warren (D-Mass.)
and Sheldon Whitehouse (D-R.I.).

Sponsored by Senator Bernie Sanders (D-Vt.), 2021 FD S.B. 1228 (NS) seeks equity for the U.S. Territories. Several provisions relate
to Medicaid. Among other things, the bill would eliminate the general Medicaid funding limits (or caps) for the territories, eliminate the

specific FMAPs [FN268] allotted to territories, temporarily increase the FMAP for Puerto Rico and the Virgin Islands to 100%, grant
Medicaid waiver authority to the territories, and allow Medicaid disproportionate share hospital payments for the territories. The bill is
co-sponsored by Senators Elizabeth Warren (D-Mass.) and Ed Markey (D-Mass. ).

Among other things, 2021 FD S.B. 1234 (NS) would award grants to states to create Pregnancy Medical Home Demonstration Projects.
The findings supplied with the bill note the high incidence of maternal mortality and morbidity in the United States relative to other
developed countries, and they note that many of these incidents are avoidable. Moreover, women of color are disproportionately
affected by maternal mortality and morbidity. The findings also highlight a successful Pregnancy Medical Home program in North
Carolina:

(10) North Carolina has established a statewide Pregnancy Medical Home (PMH) program, which aims to reduce adverse maternal
health outcomes and maternal deaths by incentivizing maternal health care providers to provide integral health care services to
pregnant women and new mothers. According to the North Carolina Department of Health and Human Services Center for Health
Statistics, the pregnancy-related mortality rate for Black women was approximately 5.1 times higher than that of White women in 2004.
Almost a decade later, in 2013, the pregnancy-related mortality rates for Black women and White women were 24.3 and 24.2 deaths
per 100,000 live births, respectively. The PMH program has been credited with the convergence in pregnancy-related mortality rates
because the program partners each high-risk pregnant and postpartum woman that is covered under Medicaid with a pregnancy care
manager.

The bill would allow grants for other states to establish such demonstrations. To be eligible, a state must, among other things, commit
to working with state and local Medicaid agencies, and the program must prioritize women enrolled in a Medicaid state plan or waiver
program. The bill is sponsored by Senator Kristen Gillibrand (D-N.Y.).

In the Senate, 2021 FD S.B. 1190 (NS) would provide enhanced federal Medicaid matching payments for direct support worker training
programs. Such programs would include:

(A) training in the core training competencies for personal or home care aides described in section 2008(b)(3)(A); and
(B) opportunities for education, training, and career advancement.

The bill aims to support workers such as personal or home care aides, direct support workers, home health aides, nursing assistants,
and other specified direct support professionals.

In December 2020, CMS published a final rule titled, 'Medicaid Program; Establishing Minimum Standards in Medicaid State Drug
Utilization Review (DUR) and Supporting Value-Based Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug
Rebate and Third Party Liability (TPL) Requirements," which is published at 85 F.R. 87000 (Dec. 31, 2020). In May 2021, CMS
published a rule that proposes to delay the effective dates and inclusion dates of certain provisions. The proposed rule is published at
86 F.R. 28742-01 (May 28, 2021).

Senator Marco Rubio (R-Fla.) introduced the State Accountability, Flexibility, and Equity for Hospitals Act of 2021 (the SAFE for
Hospitals Act) on June 10, 2021. The bill would reform how states' allotments for Medicaid disproportionate share hospital payments
are calculated. In a press release, Senator Rubio explained what the bill (2021 FD S.B. 2021 (NS)) would do:

¢ Gradually change the DSH allocation formula so states' allocations are based on the number of low-income earners living in the state,
as a percentage of the total U.S. population earning less than 100 percent of the Federal Poverty Level (FPL).

¢ Prioritize DSH funding to hospitals providing the most care to vulnerable patients, while providing states with the necessary flexibility
to address the unique needs of hospitals in each state.

¢ Expand the definition of uncompensated care to include costs incurred by hospitals to provide certain outpatient physician and clinical
services, which is a change recommended by MACPAC.

* Allow states to reserve some of their DSH funding allocations to be used in future years in order to give hospitals more certainty or
consistency in the amount of DSH funding they can expect when planning for the future. IFN269]

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Representative Ann McLane Kuster (D-N.H.) and others are sponsoring 2021 FD H.B. 3514 (NS), which would eliminate what is known
as the Medicaid Inmate Exclusion. This exclusion terminates Medicaid for incarcerated individuals. Representative Kuster explained in
a press release why this bill is important to her:

'The Medicaid Inmate Exclusion (MIE) is an outdated, flawed policy which contributes to a vicious cycle of addiction, incarceration,
and recidivism that devastates families and communities, and drains state and local budgets while harming public health and our
economy . . . . The Humane Correctional Health Care Act would help break the cycle by investing in adequate treatment and ensuring
individuals who are involved in the justice system have the opportunity to heal, recover, and make valuable contributions to our
communities. States should not be on the hook for billions in health care spending on incarcerated Americans who should have
Medicaid coverage. I'm pleased to reintroduce this bipartisan, common-sense measure alongside my Bipartisan Addiction and Mental

Health Task Force co-chair, Rep. Brian Fitzpatrick, and | urge leadership in both the Senate and the House to consider this legislation."
[FN270]

Congresswoman Stacey Plaskett (D-V.I.) and others are sponsoring 2021 FD H.B. 3434 (NS), which seeks to improve the way the
territories are treated under the Medicaid and Medicare programs. As it relates to Medicaid, the bill would eliminate the general
Medicaid funding caps, eliminate the specific FMAPs for territories, and permit Medicaid disproportionate share hospital payments for

the territories, /FN271] According to Congresswoman Plaskett, the territories are treated unfairly when it comes to Medicare and Medicaid
funding:

'People in the territories should have just as much access to health care as anyone else. With federal attention focused on how health
care disparities have contributed to the financial crisis in the territories, we believe that this is an opportune time to press the issue of
Medicaid and Medicare. The inequities in federal funding provided to the territories for Medicaid and Medicare has placed a significant
financial burden on local governments, including in the U.S. Virgin Islands, and has further exacerbated their respective financial
situations. It has also put access to affordable health care out of reach for too many Virgin Islanders, making our hospitals' emergency
rooms the primary health care provider for the one-third of our population without health insurance, which contributes to unmanageable

costs in uncompensated care [,]" *N?"7I

House Bill 3407 (2021 FD H.B. 3407 (NS)) would enact the Mothers and Offspring Mortality and Morbidity Awareness (MOMMA'S) Act.
The bill is a multifaceted attempt to improve maternal health care in the United States. Among other things, the bill would ensure oral
health services for pregnant and post-partum women, and it would ensure post-partum coverage for one year after the birth of a child.
The bill would grant states enhanced federal funding for such coverage, but a maintenance-of-effort requirement would be enforced.
The bill is sponsored by Representative Robin Kelly (D-Ill.) and others.

In the House, 2021 FD H.B. 3337 (NS) would enact the Birth Access Benefiting Improved Essential Facility Services (BABIES) Act.
That act would require HHS to create a Medicaid demonstration program testing innovative payment models for freestanding birth
center services for women with a low-risk pregnancy. The bill aims to increase access to these services and to improve the quality and
scope of such services.

Texas is one of 12 states that have not yet adopted the Affordable Care Act's Medicaid expansion. IFN273] fy bill sponsored by
Representative Lloyd Doggett (D-Tex.) and dozens of other lawmakers calls for a demonstration project that would allow political
subdivisions within a state to bypass state government and implement the expansion on their own. The bill is 2021 FD H.B. 3961 (NS).

Senator Bob Casey (D-Penn.) and others are sponsoring 2021 FD S.B. 2210 (NS), which would enact the Better Care Better Jobs Act.
The bill would make significant investments in home- and community-based services by increasing access to such care and ensuring
a well-compensated health care workforce. Among other things, the bill calls for state planning grants to strengthen and expand
home- and community based services, make permanent the state option to provide community spouses protection against spousal
impoverishment, and make the Money Follows the Person program permanent. In a news release, Senator Casey explained why this
bill is important:

'For millions of families, and especially for women, home and community-based services are a bridge to work and a bridge to economic
security. The Better Care Better Jobs Act would not only enable more older adults and people with disabilities to remain in their homes,
stay active in their communities and lead independent lives, it would also create jobs and lead to higher wages for care workers, who

are predominantly women and people of color. This legislation is critical to advancing equity, spurring economic recovery and improving

quality of life for older adults and people with disabilitiesi.]* "N24!

CMS issued an Informational Bulletin to advise states about the vacation of the 2019 Public Charge final rule released by the

Department of Homeland Security. IFN275] The 2019 rule supplanted 1999 guidance. IFN276] The public charge rule is an immigration
rule; it provides that individuals cannot be admitted to the United States if they are likely to be a public charge, that is, someone largely
dependent on the government. The 1999 guidance did not consider receipt of Medicaid benefits in the public charge determination
(with the exception of institutional long-term care), but the 2019 rule directed that receipt of most Medicaid benefits be considered in
that determination. CMS' latest guidance advises that the 2019 rule has been vacated and is no longer effective. The Department of
Homeland Security has stopped applying the 2019 rule and has reverted to the 1999 guidance. CMS reminded states that they may not
report receipt of Medicaid benefits to the Department of Homeland Security:

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CMS reminds states of their responsibility to safeguard applicant and beneficiary information. States may only share information about
an applicant or beneficiary when sharing that information is directly related to administration of the Medicaid state plan in accordance
with section 1902(a)(7)(A) of the Social Security Act, implemented at 42 CFR part 431, subpart F. Under section 2101(a) of the Act and
42 C.F.R. ? 457.1110, state agencies administering a separate CHIP are also required to comply with provisions at 42 CFR part 431,

subpart F. Under longstanding policy, sharing information with DHS about an applicant's or beneficiary's Medicaid or CHIP coverage for

purposes of a public charge determination is generally not directly related to the administration of the state plan. [FN277]

Sponsored by Senator Raphael Warnock (D-Ga.) and others, 2021 FD S.B. 2315 (NS) would enact the Medicaid Saves Lives Act. That
act would create a fallback federal program to provide Medicaid coverage for individuals in non-expansion states who earn up to 138%
of the federal poverty level. Additionally, the bill would dramatically increase the financial incentives for expansion in the American
Rescue Plan by increasing the FMAP from 5 percentage points in the American Rescue Plan to 10 percentage points and increasing
the duration of these from funds from eight quarters to 40 quarters. Senator Tammy Baldwin (D-Wis.) one of the co-sponsors, who
represents a non-expansion state, explained what the bill would do:

The Medicaid Saves Lives Act would provide health insurance to Americans with low incomes in the 12 states that have refused to
fully expand their state Medicaid programs under the Affordable Care Act. By closing the coverage gap in these states and providing
free and affordable health insurance to millions of Americans, the Medicaid Saves Lives Act would also provide access to preventative

health care services; improve health outcomes and prevent premature deaths; lower costs for uncompensated care, which would in turn

reduce hospital and provider closures; and improve economic mobility for Americans with low-incomes by enabling them to work. [FN278]

Senator Baldwin also explained what her state's refusal to expand Medicaid means for her constituents:91 ,000 individuals in the state
that would qualify for coverage if the state expanded Medicaid have been denied coverage, and the state is foregoing $1.6 billion in

federal funds for the expansion. /"N27®!

The Commonwealth Fund published a post demonstrating how the proposed increase in the American Rescue Plan's incentives
would benefit the non-expanding states. In Wisconsin, for example, the state is missing out on nearly $1.1 billion in American Rescue
Plan funds by not expanding Medicaid. Under the Medicaid Saves Lives Act, the state would be forfeiting about $14 billion. The post

provides the same analysis for all non-expanding states. [FN280]

Among other things, 2021 FD H.B. 3963 (NS) would extend Medicaid eligibility for the last 30 days of incarceration if the incarcerated
individual is otherwise eligible for Medicaid coverage.

In the House, 2021 FD H.B. 5007 would require Medicare and Medicaid providers to be vaccinated against COVID-19 once the vaccine
receives full federal approval. Exceptions for medical or religious reasons would apply. In Medicaid, the bill would require states to
amend their State Plans to require providers to be vaccinated.

In the Senate, 2021 FD S.B. 2646 (NS) would require states to provide Medicaid coverage for survivors of a disaster or emergency, as
defined in the bill. Income thresholds would apply, and the bill would allow for more lenient eligibility and enrollment requirements, like
presumptive eligibility, continuous eligibility, and simplified verification. The bill would create an option for states to provide home- and
community-based services under these circumstances, regardless of the level of care.

CMS published a rule proposing changes to its policy on Medicaid provider payment reassignment. The agency explains the proposed
changes in the summary of the rule:

This proposed rule would reinterpret the scope of the general requirement that state payments for Medicaid services under a state plan
must be made directly to the individual practitioner providing services, in the case of a class of practitioners for which the Medicaid
program is the primary source of revenue. Specifically, this proposal, if finalized, would explicitly authorize states to make payments

to third parties to benefit individual practitioners by ensuring health and welfare benefits, training, and other benefits customary for

employees, if the practitioner consents to such payments to third parties on the practitioner's behalf. [FN281]
In an email update from Medicaid.gov, CMS provided some context for the proposed rule:

Today's rule proposes to allow Medicaid state agencies to make deductions from Medicaid payments due to certain individual
practitioners in order to make payment to third parties on behalf of those practitioners for typical employee benefits, if the practitioner
has consented to such deductions. This rule would apply to the class of individual practitioners for whom Medicaid is their primary
source of revenue. Many of these workers provide home and community-based services. These practitioners serve our most vulnerable
individuals where they are enabling Medicaid beneficiaries to remain in their homes and communities. These changes would make it
easier for these practitioners to enroll in, or pay for, customary employment benefits like health insurance and skills training. The rule
would also help state Medicaid agencies by easing administrative burden, while providing additional flexibility to operate their programs
more efficiently and effectively.

The Reassignment of Medicaid Provider Claims proposed rule comes in response to a 2020 United States district court ruling that
vacated a 2019 final rule. The 2019 rule prohibited states from making these types of payments to third parties. Today's proposed rule

would reestablish this payment flexibility. "282!

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The Secretary of HHS declared a public health emergency at the start of the COVID-19 pandemic in this country. It has been extended
several times and is still in effect. CMS indicates that managing health care during the emergency period is its priority; however,

the agency granted many waivers and flexibilities during the emergency period, which will eventually end. In anticipation of that,

CMS has issued guidance, in the form of a State Health Official letter, advising states how to proceed once the emergency period
ends. First, it outlines when each of the flexibilities is set to expire. It then addresses situations in which a state opts to terminate the
use of a flexibility before the emergency period ends or continue its use after the period ends. The guidance sets out the regulatory
requirements a state must follow when it discontinues use of a flexibility. CMS explains that, typically, a state need not take action
when it terminates the use of a flexibility unless doing so results, in, say, terminating coverage or a reducing benefit. In those cases, the
state may have to comply with certain federal regulatory requirements. The letter also addresses how to handle the transition back to
normal program activities ? how to handle applications in process and so forth. Finally, the letter explains that CMS will be issuing later
guidance on program integrity considerations states must make as they contemplate making permanent changes to their programs.

[FN283] |, conjunction with the guidance, CMS has now made two tools available. The first is titled, 'General Transition Planning Tool
for Restoring Regular Medicaid and Children's Health Insurance Program Operations after Conclusion of the Coronavirus Disease
2019 Public Health Emergency," which CMS says guides the user through an assessment of actions that need to be addressed to
ensure a smooth transition. The second tool is titled, 'Medicaid and Children's Health Insurance Program COVID-19 Public Health
Emergency Eligibility and Enrollment Pending Actions Resolution Planning Tool," which will help states resolve extant enrollments
during the transition. Both tools are available on Medicaid.gov. Based on stakeholder feedback, CMS is now updating the December
2020 guidance in two key ways:

Extending the timeframe for states to complete pending eligibility and enrollment actions to up to 12 months after the month in which
the PHE ends [; and]
[clompleting an additional redetermination for individuals determined ineligible for Medicaid during the PHE[. [FN284]

CMS released an Informational Bulletin advising states about complying with Medicaid Third Party Liability rules, particularly changes
to third-party liability enacted in the Bipartisan Budget Act of 2018 (P.L. 115-123) and the Medicaid Services Investment and
Accountability Act of 2019 (P.L. 116-16). CMS conducted a survey of all 50 states, the District of Columbia, and the territories, and

discovered that most of these governments have not amended their State Plans to comply with the two acts identified above. [FN285]

CMS issued three guidance documents on COVID-related matters. First, CMS issued a State Health Official letter giving guidance
on Medicaid and CHIP coverage of COVID testing under the American Rescue Plan and of certain habilitation services during the

COVID-19 public health emergency. IFN286] Second, the agency released guidance on the temporary increased and enhanced FMAP
under the American Rescue Plan for Medicaid and CHIP coverage of vaccines and vaccine administration. That letter also discusses

the temporary increased FMAP for adopting the Medicaid expansion. [FN287] Third, CMS released guidance on vaccine hesitancy,
including strategies and opportunities that Medicaid and CHIP programs can use to ameliorate such hesitancy. [FN288]

In the House of Representatives, 2021 FD H.B. 5260 (NS) seeks to reduce the price of prescription drugs in Medicare and Medicaid. As
it relates to Medicaid, the bill would, among other things, create a state option to pay for covered outpatient drugs through risk-sharing
value-based agreements.

The Compacts of Free Association (COFA) define the rights of citizens of the freely associated states, which include Federated States
of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau. The Consolidated Appropriations Act, 2021 (P.L.
116-260) required the states and the District of Columbia to extend Medicaid eligibility under the State Plan to citizens of the freely

associated states living in the United States under COFA. [FN2891 CMS has now issued guidance on implementing this requirement. The
guidance, in the form of a State Health Official letter, addresses these topics:

* Extension of Medicaid eligibility to COFA migrants

« Changes to the Federal Exchange eligibility and enrollment platform (Federal platform) and
¢ Federal Data Services Hub to implement the change to COFA migrants' Medicaid eligibility
* Operational considerations for states

* Applicable Federal Medical Assistance Percentage (FMAP)

¢ Territory considerations [FN290]

XV. SELECTED STATE ACTIVITY

In Alabama:

House Bill 331 (2021 AL H.B. 331 (NS))} has been adopted. The bill provides for an appropriation from the Children's First Trust Fund to
the Medicaid Agency for the fiscal year ending September 30, 2022. The bill also calls for an additional appropriation from the tobacco
settlement funds to the Medicaid Agency and to the Department of Senior Services for the Medicaid waiver.

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In Arizona:

House Bill 2885 (2021 AZ H.B. 2885 (NS))} would appropriate Medicaid funds to expand and operate the Healthy Communities Health
Care Program on a state-wide basis, focusing especially on rural and underserved communities. The program would:

* allow community service providers and state and local governments to screen vulnerable persons for program eligibility;

* manage enrollment and insurance, and provide referrals to and scheduling for primary care physicians that accept both Medicare and
Medicaid;

¢ provide telehealth for specified conditions and provide remote patient monitoring at no cost to the patient;

¢ provide access to trained life coaches who can help with transportation and other barriers to health;

* develop a mobile-friendly application that program participants can use to develop self-management skills and other good habits;
* provide access to advanced medical nutritional therapy; and

¢ coordinate and provide access to reimbursable broadband communications to facilitate telehealth.

In Arkansas:

House Bill 1548 (2021 AR H.B. 1548 (NS)) enacts the Personal Care Medicaid Reimbursement Act. Among other things, it requires a
reexamination of personal care reimbursement rates whenever the state or federal minimum wage is increased to a rate higher than
the rate applicable to Arkansas employees. The findings supplied with the bill note the importance of personal care services in avoiding
institutional care. Allowing people to safely stay in their homes allows them to maintain a measure of freedom and independence, and it
saves the state money, according to the bill's authors. The bill was adopted on April 5, 2021.

Senate Bill 189 (2021 AR S.B. 189 (NS)) has been adopted. The bill amends existing statutory provisions setting up an assessment on
medical transportation providers in the Medicaid program. Among other things, the bill amends the definition of 'medical transportation"
to include non-emergency ambulance services. It also adds language to an existing provision on exemptions to the assessment
program. The new language reads as follows:

(c) This subchapter does not:

(1) Impact scheduled appointments of nonemergency transportation providers that are contracted with the Department of Human
Services; or

(2) Subject nonemergency transportation providers that are contracted with the department to any part of the upper payment limits or
access payments.

Finally, the bill declares an emergency, making the bill immediately effective. The emergency clause provides,

It is found and determined by the General Assembly of the State of Arkansas that medical transportation providers are struggling to
remain viable in providing access to healthcare services; that the increased payments provided for under this act will allow medical
transportation providers to provide access to quality health care; that the Department of Human Services must develop a state plan
amendment that must be approved by the Centers for Medicare and Medicaid Services before the increased payments can be
distributed to the medical transportation providers; and that this act is immediately necessary to ensure that medical transportation
providers remain viable to provide healthcare services to the citizens of Arkansas. Therefore, an emergency is declared to exist, and
this act being immediately necessary for the preservation of the public peace, health, and safety... .

House Bill 1847 (2021 AR H.B. 1847 (NS)) was adopted on April 26, 2021. The bill changes eligibility requirements for long-term care
for the low-income disabled working person category of Medicaid. The bill adds this additional statutory language:

(d)(1) To the extent approved by the federal government, the department shall exclude any assets accumulated in a person's
independence account and any income or assets from retirement benefits earned or accumulated from employment income or
employer contributions while the person was employed and eligible for and receiving benefits under the low-income disabled working
person category of Medicaid eligibility, as established under ? 20-77-1201 et seq., when determining that person's financial eligibility
and cost-sharing requirements, if any, for the long-term care medical assistance.

(2) As used in this section, 'independence account' means an account approved by the department that consists solely of savings, and
dividends or other gains derived from those savings, from income earned from paid employment after the initial date on which a person
began receiving medical assistance under the low-income disabled working person category of Medicaid eligibility, as established
under ? 20-77-1201 et seq.

If passed, 2021 AR H.B. 1546 (NS) would have phased out the soft drink tax that was enacted in 1983 to fund Medicaid; Medicaid
would then have been funded with general revenue funds. The bill was introduced on February 23, 2021, and it was later amended.
The bill twice failed third reading, and it has now died.

In California:

Federal Medicaid law requires that certain in-home services, including personal care and home health care, be verified with an
electronic verification system. In order to ensure that the state complies with the law and continues to receive federal funds for these

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services, the current version of Senate Bill 133 (2021 CA S.B. 133 (NS)) would, among many other things, authorize the Department of
Health Care Services to develop and implement such a program and mandate that providers comply with these requirements.

In Colorado:

House Bill 1227 (2021 CO H.B. 1227 (NS)) directs the Department of Health Care Policy and Financing to develop demonstration-of-
need criteria for new Medicaid nursing facilities. The bill only applies to nursing facilities seeking certification after June 30, 2021. The
department is authorized to exempt facilities with five or fewer Medicaid beds. Governor Polis signed the bill on May 27, 2021.

Governor Polis signed 2021 CO S.B. 214 (NS) on May 4, 2021. The bill will temporarily provide additional payments for certain
hospices that treat dually eligible patients unable to secure a bed in a nursing facility in which the patient could receive hospice
services. The findings supplied with the bill describe the problem:

(1) The general assembly finds and declares that as a result of the presence of the COVID-19 virus in the state and other
circumstances, eligible patients in need of a nursing-facility level of care who are in their final weeks of life may not be able to find an
appropriate placement in a nursing facility where they can receive hospice care. Without an available or appropriate nursing facility bed,
hospice providers have made residential hospice beds available to these eligible patients despite receiving only reimbursement under
the federal Medicare program for hospice services but not for expenses related to room and board. Therefore, the general assembly
declares that it is appropriate to make available to these qualified hospice providers for a limited period of time a state payment that is
equal to the state share of funding under the medical assistance program that would otherwise be paid to a nursing facility if the nursing
facility were able to provide a residential bed for an eligible patient.

The Department of Health Care Policy and Financing gave notice that it will be pursuing a State Plan amendment to expand targeted
case management qualifications. In the notice, which is published at 2021 CO REG TEXT 594546 (NS) (Sept. 25, 2021), the
Department explains why the amendment is needed:

The Department of Health Care Policy and Financing (Department) intends to submit a State Plan Amendment to the Centers for
Medicare and Medicaid Services (CMS) to expand targeted case management qualifications by aligning with national standards,
effective October 10, 2021. The expansion is to address recruitment and retention challenges at case management agencies. Case
management agency staffing challenges have negative impacts on Long Term Services and Supports members and this change[] is
intended to alleviate staffing challenges.

In Connecticut:

If passed, 2021 CT S.B. 813 (NS) would provide up to three months of retroactive coverage for Medicaid home health services. The
look-back period would be 60 months.

Also in Connecticut, 2021 CT S.B. 818 (NS) seeks to avoid spousal impoverishment of a community spouse of an institutionalized
person. It passed the Senate on June 7, 2021. The latest version of the bill would direct the Commissioner of Social Services to submit
a report on the cost and feasibility of permitting a community spouse of an institutionalized spouse to retain the maximum resource
amount allowable for such community spouse pursuant to federal law.

In Florida:

House Bill 443 (2021 FL H.B. 443 (NS)) called for the state to adopt the Affordable Care Act's Medicaid expansion. According to the

Kaiser Family Foundation, the bill had little hope of passing in the Republican-controlled legislature. [FN291] Ultimately, the legislature
adjourned before the bill advanced.

Governor Ron DeSantis (R) signed 2021 FL H.B. 905 (NS) on June 21, 2021. The bill creates new statutory provisions relating to

approval of PACE IFN292] organizations. It authorizes the Agency for Health Care Administration, in consultation with the Department
of Elderly Affairs, to approve PACE entities and to consider and review applications on a continuous basis. The bill also sets forth the
documentation that prospective PACE organizations need to file with the agency before seeking funding, and it sets out how PACE
organizations will be held accountable for the quality of care they provide.

In Georgia:

House Bill 209 (2021 GA H.B. 209 (NS)) would have established a Medicaid expansion program for individuals earning up to 150%
of the federal poverty level. The plan would have called for Medicare fee-for-service benefits, subsidies to pay for coverage under the
program, subsidies to pay for premiums on a Marketplace plan for individuals with income from 151% to 500% of the federal poverty
level, and a Medicare fee-for-service plan option for certain individuals, among other things. It did not pass before the legislature
adjourned.

Also in Georgia, 2021 GA H.B. 214 (NS) would have called for a Medicaid buy-in program for individuals who are uninsured and not
eligible for Medicaid. It did not pass this session.

¢ If passed, 2021 GA S.B. 50 (NS) would have created a premium assistance program for individuals to purchase insurance through
the Marketplace. The program would have been available for individuals earning up to 138% of the poverty level, including those not
currently eligible for Medicaid. However, to be eligible, the state would have had to determine that the individual was not 'effectively
covered through other public assistance programs for health care needs."Those enrolled in the program would have had to pay a

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personal responsibility premium of no more than 5% of their income as a condition of coverage. The program, which appeared to be
an alternative to a Medicaid expansion, would have been contingent on getting full federal matching funds for fiscal year 2022 and
increasingly lower matching funds each subsequent year, with a matching rate of no less than 90% in fiscal year 2026 and beyond. It
did not pass during the 2021 session.

House Bill 163 (2021 GA H.B. 163 (NS)) will direct the Department of Community Health to seek a State Plan amendment to implement
express lane eligibility for determining whether a child meets eligibility criteria for Medicaid or the PeachCare for Kids Program. Once
implemented, the department can rely on data from the Supplemental Nutrition Assistance Program (SNAP) and other identified
programs to enroll or renew coverage. Governor Brian Kemp (R) signed the bill on May 4, 2021.

Also in Georgia, 2021 GA S.B. 172 (NS) would have authorized funding for the Affordable Care Act's Medicaid expansion. The
authorization would have been valid only as long as the federal government provided a 90% match rate. Georgia is one of 12 states

that have not adopted the expansion. IFN293] The bill did not pass this session.
In Hawaii:

Citing the economic damage done by the pandemic, Senate Bill 1132 (2021 HI S.B. 1132 (NS)) would have created a Medicaid
Sustainability Program to draw down additional federal funds by assessing a fee on health insurers. Senate Bill 1132 passed the
Senate on March 9, but it ultimately did not pass before adjournment. Similarly, 2021 HI S.B. 1130 (NS) would have continued the
Hospital Sustainability Program and garner more Medicaid funding by assessing a fee on hospitals. It also failed to pass this session.
As a way to draw more federal Medicaid funds for nursing facilities, 2021 HI S.B. 1131 (NS) would have continued the Nursing Facility
Sustainability Program and assess a fee to nursing facilities. It also did not pass before adjournment.

Also in Hawaii, 2021 HI S.B. 1285 (NS) would have required any hospital serving a community with more than 500 individuals covered
by the Compact of Freely Associated States to implement certain measures to ensure diversity:

Any hospital or other medical facility that serves a community including more than five hundred persons eligible for benefits pursuant
to the Compact of Free Association Act of 1985, P.L. 99-239, or the Compact of Free Association between the United States and the
Government of Palau, P.L. 99-658, shall:

(1) Establish and implement a program of diversity and inclusion training for all staff; and

(2) Hire interpreters and community healthcare workers as necessary to effectively communicate with and provide culturally sensitive
services to the community.

According to the findings supplied with the bill, residents of such communities have been disproportionately affected by the pandemic.
The COVID relief bill that Congress passed in December 2020 (the Consolidated Appropriations Act of 2021) restores Medicaid
benefits for this group. As these individuals enter the ranks of the insured, this bill would have ensured that they did not experience

prejudice or discrimination in health care. [FN294] an amended version of Senate Bill 1285 passed the Senate on March 9, but ultimately
the bill did not pass before adjournment.

A concurrent resolution dealing with eligibility for home- and community-based services passed the Senate on March 31, 2021,

but it did not pass the House before adjournment. The resolution, 2021 HI S.C.R. 119 (NS), called for the Department of Health
Developmental Disabilities Division to convene a task force to determine the feasibility of changing its eligibility criteria for the Home
and Community-Based Services Medicaid Waiver for Individuals with Developmental Disabilities. The authors of the resolution believe
that the exclusions for participation in this waiver program are unnecessarily broad:

WHEREAS, pursuant to section 11-88.1-5(a), Hawal! Administrative Rules, to be considered as having an developmental disability,
an individual must have, among other factors, a diagnosis that meets the definition of an eligible condition for a severe and chronic
disability, including cerebral palsy; epilepsy; autism spectrum disorder; or a neurological condition, central nervous system disorder, or
chromosomal disorder that results in impairment in both general intellectual functioning and adaptive behavior; and

WHEREAS, pursuant to section 11-88.1-5(a)(3), Hawall Administrative Rules, an individual is ineligible for the Medicaid I/DD Waiver if
the individual's impairments are primarily from dementia, mental illness, an emotional disorder, substance abuse, sensory impairment, a
learning disability, attention deficit hyperactivity disorder, a spinal cord injury, or a neuromuscular disorder; and

WHEREAS, section 11-88.1-5(a)(3), Hawall Administrative Rules, unfairly excludes from eligibility from services a number of individuals
who would otherwise be eligible based on their developmental disabilities[.]

In Illinois:

If passed, 2021 IL S.B. 1826 (NS) would create the Consumer Choice in Maternal Care for African-American Mothers Pilot Program.
The findings supplied with the bill note that, in Illinois in 2018, Black women were six times more likely than White women to die of a
pregnancy-related condition and that the great majority of these deaths are preventable. Significantly, 2019 data showed that women
insured by Medicaid are much more likely than women with private insurance to experience severe maternal morbidity. Moreover, Black
women are much more likely to prefer a home birth, but there are not nearly enough midwives to serve their needs. According to the
findings,

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Expanding Medicaid coverage to include perinatal and intrapartum care by certified professional midwives will not contribute to
increased taxpayer burden and, in fact, will likely decrease the Department of Healthcare and Family Services' expenditures on
maternal care while improving maternal health outcomes within the Black community in Illinois.

The bill therefore calls for a Medicaid voucher pilot program:

The Task Force on Infant and Maternal Mortality Among African Americans shall partner with community-based maternal care providers
to develop rules and regulations for a Medicaid voucher pilot program to expand consumer choice for Black mothers that includes
planned home birth services and in-home perinatal and postpartum care services provided by racially concordant nationally accredited
certified professional midwives. The Department of Healthcare and Family Services shall implement the pilot program no later than
January 1, 2023 and the pilot program shall operate for a 5-year period. On January 1, 2024, and each January 1 thereafter through
January 1, 2028, the Task Force shall submit a report to the General Assembly that provides a status update on the pilot program and
annual impact measure reporting.

The program would use a maternity episode payment model that would provide a single payment for all services across the prenatal,
intrapartum, and postnatal period, up to 12 weeks postpartum.

¢ Senate Bill 2292 (2021 IL S.B. 2292 (NS)) would, with federal approval, create the Bridge to Community Supports for Young Adults
with Developmental Disabilities Waiver Program. The program would serve young adults with developmental disabilities who are
between the ages of 18 and 27, beginning when they graduate from high school or are no longer eligible for special education services
and ending when they are removed from the Prioritization for Urgency of Need for Services database or on the day before their 27th
birthday, whichever occurs first. The program would provide a menu of self-directed service choices and would cover them up to
$15,000 per individual per year. The services could include day activities, employment and training supports and services, health

and wellness supports, assistive technology devices to allow participation in covered services, independent living skills, and respite
services, among other things.

In Indiana:

Senate Bill 261 (2021 IN S.B. 261 (NS)) would direct the Office of the Secretary of Family and Social Services to apply for a Medicaid

State Plan amendment to establish a new long term care insurance partnership program. [FN295] An amended version of the bill passed
the Senate on February 22, 2021.

Also in Indiana, 2021 IN S.B. 51 (NS) would allow the Office of the Secretary of Family and Social Services to apply for a Medicaid
State Plan amendment to reimburse school corporations for medically necessary school-based covered services that are provided
pursuant to federal or state mandates. An amended version of the bill passed the Senate on February 17, 2021.

In Kansas:

If passed in Kansas, 2021 KS H.B. 2372 (NS) would have established an assessment for Medicaid ambulance service providers. The
proceeds of the assessment would have been used to increase payment rates. The bill did not pass this session.

In Kentucky:

A resolution, 2021 KY H.C.R. 55 (NS) would have created the 1915(c) Home-and Community-Based Services Waiver Redesign Task
Force to review previous waiver redesign efforts and to provide recommendations to ensure the quality and stability of 1915(c) waiver
services. The findings supplied with the bill noted the high demand and long waiting list for such waiver services. The task force would
have been directed to examine ways to increase services in a cost-efficient manner. An amended version of the resolution passed the
House on March 4, 2021, but the bill did not pass the Senate before adjournment.

In Louisiana:

Introduced on April 12, 2021, 2021 LA H.B. 186 (NS) would have authorized the Department of Health to enter into interagency data-
sharing agreements with the Department of Revenue and the Department of Child and Family Services in order to improve Medicaid
program administration and integrity. Critics claimed that the bill would have allowed the state to redirect child support money meant for
children and use it reimburse the state for the child's Medicaid costs. The bill's sponsor, Representative Tony Bacala, disagreed with
that reading of the bill. He explained what the bill is meant to accomplish:

''ll give you just an example. You could have one parent, you could have two children. One parent makes 20 grand. The other makes
100,000. The parent that makes 20,000 applies and receives Medicaid. And the parent that makes a hundred thousand, is not held
responsible for the children's welfare at all.

'So you would seek to determine where that hundred thousand earner is and tell them, "listen, the state's paying for your children's
healthcare. You make enough money that you should be responsible for it,' and then try to get reimbursement from them. That's it.

'| will speak very clearly. We're not trying to take money, child support payments, from anybody." IFN296]

Representative Bacala said that he was open to amendments to clarify the purpose of the bill and ensure that it was not interpreted as
a bill that harms families. "9" The bill was amended and substituted and is now 2021 LA H.B. 698 (NS). The bill passed both houses,
both Governor John Bel Edwards (D) vetoed it on July 1, 2021. IFN298] The legislature has now adjourned.

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If passed, 2021 LA H.B. 485 (NS) would have created the Medicaid Managed Care Authority to oversee the Medicaid managed care
program. The findings supplied with the bill noted that the Department of Health created the managed care program by rule and has
been administering it. The program has grown tremendously, and now 90% of Medicaid participants are served in the managed care
program. By creating the Medicaid Managed Care Authority, the bill would have been providing the proper degree of oversight for the
program, according to the findings. The bill was introduced on April 12, 2021. It did not pass before adjournment.

¢ In 2018, CMS announced a demonstration that would allow states to treat those with a serious mental illness in an inpatient setting;
normally, the IMD (Institute for Mental Disease) exclusion would exclude coverage for these services when provided in a facility with
more than 16 beds. "79°! A Louisiana bill, 2021 LA H.B. 598 (NS), would have directed the Secretary of the Department of Health to
seek federal approval of a Section 1115 waiver to participate in this demonsiration. It did not pass this session.

If passed, 2021 LA S.C.R. 32 (NS) calls for the re-creation of a previously-existing task force that studied health delivery and financing
in the Baton Rouge area. Once re-created, the task force would be directed to study these things:

(1) Barriers to access to health care faced by low- to moderate-income persons.

(2) Impacts of cuts to federal disproportionate share hospital funding and Louisiana's expansion of Medicaid in 2016 on patient access
to health services.

(3) Effects on public health of the closure of the state-operated public hospital in Baton Rouge and privatization of the services formerly
delivered there.

(4) Impacts on private hospitals which do not operate under a cooperative endeavor agreement with the state of providing
uncompensated care.

(5) Policies which could expand the capacity of public and private urgent care clinics to meet the health care needs of medically
underserved populations.

The bill was introduced on April 26, 2021, and it has now passed both chambers.

In a notice published at 2021 LA REG TEXT 549477 (NS) (Oct. 11, 2021), the Public Health Department gave notice of emergency
rules that relax Medicaid telehealth rules in a declared emergency:

A. In the event of a declared emergency, Medicaid may temporarily cover services provided through the use of an interactive audio
telecommunications system, without the requirement of video, if such action is determined to be necessary to ensure sufficient services
are available to meet recipients' needs.

In Maine:

¢ In Maine, 2021 ME S.P. 114 (NS) has been adopted. The bill will gradually increase coverage for post-partum care to 12 months for
qualified women with income at or below 200% of the non-farm income official poverty line. Specifically, the period would be enlarged
to six months from January 1, 2022, to June 30, 2022; to nine months from July 1, 2022, to June 30, 2023; and to 12 months from July
1, 2023, to December 31, 2026. The bill will also extend the same coverage on the same graduated schedule to noncitizen individuals
legally residing in the state, to the extent permitted by federal law. The bill will also extend coverage under the same timeframes to
noncitizen individuals legally residing in the state who are under 21 years old.

In Maryland:

* If passed, 2021 MD H.B. 470 (NS) would have established a universal health care program for all state residents regardless of
income, assets, health, or the availability of other coverage. The program would have subsumed Medicaid, Medicare, and Marketplace
plans. It did not pass before adjournment.

In Michigan:

Senate Bill 412 (2021 MI S.B. 412 (NS)) passed the House and was sent to the Senate on September 29, 2021. The bill would change
existing provisions on prior authorization of prescription drugs in the Medicaid program. More specifically, the bill would exempt from the
prior authorization process certain drugs to treat substance use disorder.

In Minnesota:

* If passed, 2021 MN H.F. 1102 (NS) would have provided that a person receiving Medicaid home- and community-based services
would not need to be reassessed for eligibility if the person temporarily (for 121 days or less) discontinues these services due to a stay
in a specified type of health facility. The bill did not pass before adjournment.

In Mississippi:

Senate Bill 2346 (2021 MS S.B. 2346 (NS)) would have extended Medicaid coverage for women for up to 12 months postpartum. The
bill was introduced on January 15, 2021; it died in committee.

If passed, 2021 MS H.B. 1013 (NS) would have abolished the Division of Medicaid and transfer all of its powers and authority to the
Medicaid Commission, which would have been established by the bill. While the bill passed the House, it died in a Senate committee.

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In Missouri:

Introduced on January 15, 2021, 2021 MS H.B. 207 (NS) would have implemented the Affordable Care Act's Medicaid expansion and
specified that expansion individuals would be given benchmark coverage. The bill died in committee. On August 4, 2020, voters in the

state approved a constitutional amendment adopting the expansion without any additional burdens or restrictions. [FN300]
In Nevada:

If approved by CMS, the state would have amended its State Plan to allow physically disabled recipients of personal care services to
be directly reimbursed for services provided to them and paid for by them. The bill, 2021 NV S.B. 93 (NS), would have also directed
that Medicaid eligibility for an incarcerated person be suspended rather than terminated. Regulations would have set out the period of
time for which the individual's eligibility could be suspended. The bill passed the Senate on May 21, 2021, but it did not pass the House
before adjournment.

In New Jersey:

If passed, 2020 NJ S.B. 3455 (NS) would change eligibility requirements for the New Jersey Workability Program (a Medicaid buy-in
program for working adults who are disabled). A statement supplied with the bill when it was introduced explains the proposed changes:

The bill expands the eligibility for this program in various ways. First, the bill removes the upper age limit for eligibility, providing that any
individual who is older than 16 may qualify. The current age requirement is between 16 and 65 years of age. Second, the bills requires
that the premium contribution established by the commissioner is to be based solely on the applicant's earned and unearned income.

In doing so, the income of the applicant's spouse cannot be considered in this determination. Third, the bill eliminates the program's
existing income eligibility limit of 250 percent of the federal poverty level and explicitly provides that a qualified applicant is not to be
subject to any eligibility requirements regarding the earned or unearned income of the applicant or the applicant's spouse. Finally, the
bill permits that an eligible applicant for the program is to remain eligible for Medicaid for up to a period of one year if, through no fault of
the applicant, a job loss occurs.

The bill would also change eligibility criteria for the Personal Assistance Services Program by removing the upper age cap (which is
currently 70 years of age).

Introduced on April 26, 2021, 2020 NJ S.B. 3663 (NS) would provide for an additional appropriation for specified Medicaid behavioral
health and addiction service providers. The statement provided with the bill summarizes who would be eligible for the funds:

[T]he bill authorizes the department to distribute supplemental reimbursements to providers who held cost-based reimbursement
contracts with the State, and who subsequently transitioned to the fee-for-service reimbursement system, equal to the difference, if
any, between the provider's billable revenues under the fee-for-service reimbursement system during FY 2019 and the value of the
provider's most recent annual cost-based reimbursement contract with the State. Only providers who have demonstrated a good faith
effort to bill Medicaid for all eligible services shall be entitled for a supplemental reimbursement.

In New York:

Introduced on February 26, 2021, 2021 NY S.B. 5255 (NS) would have repealed the Medicaid spending growth cap. The bill provided,
in pertinent part,

Section 1. Sections 91 and 92 of part H of chapter 59 of the laws of 2011 relating to the year to year rate of growth of Department of
Health state funds and Medicaid funding are REPEALED.

It did not pass this session.

Senate Bill 5956 (2021 NY S.B. 5956 (NS)) would have allowed physician assistants to serve as primary care providers in the Medicaid
managed care program. It did not pass before adjournment.

Also in New York, 2021 NY S.B. 5028 (NS) sought to loosen eligibility restrictions for Medicaid home health services. Had the bill
passed, this restriction would been eliminated:

needing at least limited assistance with physical maneuvering with more than two activities of daily living, or for persons with a
dementia or Alzheimer's diagnosis, as needing at least supervision with more than one activity of daily living, provided that the
provisions related to activities of daily living in this paragraph shall only apply to persons who initially seek eligibility for the program on
or after October first, two thousand twenty.

Senate Bill 2542 (2021 NY S.B. 2542 (NS)) would have amended the definition of the look-back period for transfers made after
October 1, 2021. It would have also exempted certain transfers made to a family member or an informal caregiver before the period of
institutional status or before the application for Medicaid for non-institutional long-term care services when these conditions are met:

(A) the transfer is in exchange for care services the family member or informal caregiver provided to the client or the client's spouse;
(B) the client or the client's spouse had a documented need for the care services provided by the family member or informal caregiver;
(C) the fair market value of the asset transferred is comparable to the fair market value of the care services provided; and

(D) the time for which care services are claimed is reasonable based on the kind of services provided.

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An amended version of the bill passed the Senate on June 3, 2021. Ultimately, it did not pass the House before adjournment.

The Department of Health gave notice of emergency rulemaking that will prevent duplicate payments for certain ground transportation
services. In short, the department will not provide non-comparable ambulance add-on payments to hospitals as well as a supplemental
add-on payment for these services. The department explained,

Based on the requirements of Chapter 56 of the Laws of 2020, eligible ground emergency transportation providers will be provided
the ability to participate in a supplemental payment in lieu of receiving reimbursement through a hospital. Article 28 hospitals currently
receive reimbursement through their acute hospital inpatient rate for ambulance services provided by the ground emergency medical
transportation providers. For ground emergency transportation providers that meet the requirements of this chapter and receive the
supplemental payment, the hospitals through which they were reimbursed will not be eligible to also receive the ambulance add-on in
the acute hospital inpatient rate.

The notice is published at 2021 NY REG TEXT 561433 (NS) (Oct. 27, 2021).
In North Carolina:

¢ The current version of Senate Bill 93 (2021 NC S.B. 93 (NS)) would direct HHS to seek approval to allow parents to retain Medicaid
eligibility if:
(i) the parent has lost custody of a child pursuant to Subchapter | of Chapter 7B of the General Statutes, (ii) the child is being served

temporarily by the foster care system, regardless of the type of out-of-home placement, and (iii) the parent is making reasonable efforts
to comply with a court-ordered plan of reunification, as determined by DHHS.

Introduced on March 31, 2021, 2021 NC S.B. 402 (NS) would expand Medicaid to any individual who meets these requirements:

(1) The individual has a modified adjusted gross income that is at or below one hundred thirty-three percent (133%) of the federal
poverty level.

(2) The individual is age 19 or older and under age 65.

(3) The individual is not entitled to or enrolled in Medicare benefits under Part A or Part B of Title XVIII of the federal Social Security
Act.

(4) The individual is not otherwise eligible for Medicaid coverage under the North Carolina State Plan as it existed on January 1, 2020.

Qualified individuals would receive benefits through an Alternative Benefit Plan that meets federal requirements. North Carolina is one

of twelve states that have not adopted the Affordable Care Act's Medicaid expansion. IFN301] The expansion proposed in this bill would
take advantage of the temporary FMAP increase called for in the American Rescue Plan; that act created an incentive for states that
have not yet adopted the Medicaid expansion to adopt it now.

Also introduced on March 31, 2021, 2021 NC S.B. 391 (NS) would repeal existing statutory provisions and adopt a new Hospital
Assessment Act to account for the Medicaid transformation process.

House Bill 507 (2021 NC H.B. 507 (NS)) would enact the North Carolina Momnibus Act. The findings supplied with the bill note the
shocking statistics on maternal mortality and morbidity and the disparities in outcomes between white women and women of color. To
work toward a solution, the bill would establish the Social Determinants of Maternal Health Task Force, which would be charged with,
among other things, making recommendations on leveraging Medicaid services to address social determinants of maternal health.

In North Dakota:

¢ North Dakota has implemented the Medicaid expansion, but the statutory authority for it expires on July 1, 2021. If adopted, 2021
ND S.B. 2222 (NS) would have removed the termination date from the statute. It would also have removed the statutory provision
that currently reads, 'The department shall inform new enrollees in the medical assistance expansion program that benefits may be
reduced or eliminated if federal participation decreases or is eliminated." The bill was introduced on January 18, 2021; it failed to pass
the second reading.

In Ohio:

The Medicaid Department gave notice of final regulations increasing reimbursement rates for home health nursing services, home
health aide services, and home health therapy services, as well as private duty nursing services. Please see 2021 OH REG TEXT
591456 (NS) (Oct. 25, 2021).

In Oklahoma:

Voters approved the Medicaid expansion on June 30, 2020, for a start date of July 1, 2021. The constitutional amendment that the

voters approved provided that the state may not impose additional restrictions on the coverage. [FN302] fv bill introduced on January 18,
2021, would have enacted the Ensuring Access to Medicaid Act. The bill noted that the state is moving into capitated managed care
for Medicaid, and it set out certain consumer protections that the state would have needed to include in its managed care contracts.
Many of those provisions had to do with time limits, payment rates, credentials for physicians and other providers, and so forth. The bill
is 2021 OK H.B. 1091 (NS). It passed the House on March 11, 2021, but it did not pass the Senate before adjournment.

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Existing law calls for a Medicaid buy-in program for disabled workers 'if funds become available."If passed, 2021 OK H.B. 1573 (NS)
would have eliminated that funding contingency. It did not advance this session.

Senate Bill 434 (2021 OK S.B. 434 (NS)) passed both houses and was sent to Governor Kevin Stitt (R), who signed it on May 28, 2021.
The bill creates an Indian Health Service, Tribal, and Urban Indian (I/T/U) Shared Savings Program to share in savings accruing to the
Oklahoma Health Care Authority from a 100% federal match rate for certain services rendered to an American Indian, Alaskan native
Medicaid patient. The bill explains,

Pursuant to guidance of the Centers for Medicare & Medicaid Services (CMS), authorized services provided by a non-I/T/U Medicaid
provider to an American Indian or Alaska Native (AI/AN) Medicaid beneficiary as a result of a referral from an I/T/U facility provider may
be eligible for the enhanced federal matching rate of one hundred percent (100%).

C. 1. The Authority shall distribute up to fifty percent (50%) of any savings that result from the I/T/U Shared Savings Program provided
for in this section to participating I/T/U facilities that have complied with the terms of this act and applicable federal law, but only after
administrative costs incurred by the Authority in implementing the I/T/U Shared Savings Program have been fully satisfied.

2. Distributions to participating I/T/U facilities shall be used to increase care coordination and to support health care initiatives for AI/AN
populations.

Also in Oklahoma, 2021 OK H.B. 2950 (NS) was adopted on May 25, 2021. To ensure Medicaid participants' access to quality
emergency and non-emergency transportation, the bill will impose an assessment on non-exempted ambulance service providers. The
purpose of the assessment is to garner additional federal payments. The funds received through the assessments and the federal funds
will then be deposited into a fund and redistributed as specified in the bill.

In Oregon:

Senate Bill 800 (2021 OR S.B. 800 (NS)) has been adopted. The bill establishes the Oregon Essential Workforce Health Care Program
to provide health care to employees of long term care facilities, residential care facilities, and in-home care agencies that participate in
Medicaid. Governor Kate Brown (D) signed the bill on July 19, 2021.

In Pennsylvania:

If passed, 2021 PA H.B. 1940 (NS) would integrate physical and behavioral health care and pharmacy services into the HealthChoices
Medicaid managed care program.

In South Dakota:

The Department of Social Services is proposing to amend its State Plan to bring provisions on third-party liability in line with federal
regulations. The notice is published at 2021 SD REG TEXT 596540 (NS) (Oct. 18, 2021).

In Texas:

Senate Bill 521 (2021 TX S.B. 521 (NS)) would have extended Medicaid coverage to 'qualified aliens" as defined by federal law after
the federally-mandated five year waiting period. The waiting period would have been waived for pregnant women. It did not pass this
session.

Seeking to avoid children chuming on and off of Medicaid, 2021 TX H.B. 290 (NS) would have called for a mid-year income check.
Following this check, and before termination of coverage, the child's parent or guardian would have been allowed to address findings
that their household income rendered the child ineligible for continued Medicaid coverage. If the child was determined ineligible and
coverage was terminated, the parent or guardian would have been notified that the child may qualify for coverage under CHIP (the
Children's Health Insurance Plan). While the bill passed the House on April 15, 2021, it did not pass the Senate before adjournment.

If passed, 2021 TX H.B. 3662 (NS) would have amended existing provisions on Medicaid managed care contracts. TX GOVT ?
533.004 sets out who the commission may contract with to provide managed care services. Had it passed, the bill would have added
these provisions:

(4) if the commission does not have an existing contract with a managed care organization in a health care service region under
Subdivision (1), (2), or (3) on September 1, 2021, wholly owned by a provider-sponsored health organization that owns and operates:

(A) two trauma facilities designated as level | trauma facilities by the Department of State Health Services under Section 773.115,
Health and Safety Code, that are located in different trauma service areas; and

(B) a hospital licensed under Chapter 241, Health and Safety Code, that is located in the health care service region.
Senate Bill 1648 (2021 TX S.B. 1648 (NS)) has been adopted. Among other things, the bill will:

¢ direct the Health and Human Services Commission, in coordination with the Department of Family and Protective Services, to develop
a process to review denials of Medicaid managed care services to foster care youth on the basis of medical necessity;

¢ direct the Health and Human Services Commission, after consultation with the Intellectual and Developmental Disability System
Redesign Advisory Committee and the STAR Kids Managed Care Advisory Committee,to study the feasibility of creating an online
portal where individuals may express interest in a Medicaid waiver program and check the status of their placement on that list;

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¢ direct the Health and Human Service Commission to develop a process to verify that Medicaid participants or their legal guardians are
informed about the consumer direction model and about their option to choose care under that model;

¢ direct the Health and Human Services Commission, in collaboration with the specified stakeholders, to develop and implement a pilot
program to provide coordinated care through a health home to children with complex medical conditions, and

* direct the Health and Human Services Commission to ensure Medicaid reimbursement for one preventive dental visit per year for
adults with a disability who are enrolled in the STAR+PLUS Medicaid managed care program.

The Health and Human Services Commission gave notice of adopted rules that amend the Medicaid State Plan to establish the
Hospital Augmented Reimbursement Program. The amendment, which is published at 2021 TX REG TEXT 588311 (NS) (Sept. 4,
2021), includes this explanation of the program:

This section establishes the Hospital Augmented Reimbursement (HARP) Program, wherein the Texas Health and Human Services
Commission (HHSC) directs payments to certain providers that serve Texas Medicaid fee-for-service patients, including eligible non-
state government owned hospitals, private hospitals, state-owned hospitals, state government-owned Institutions for Mental Diseases
(IMDs), and private IMDs. This section also describes the methodology used by HHSC to calculate and administer such payments.

A provider is eligible for a payment under this section only if HHSC has submitted and CMS has approved a state plan amendment
permitting HHSC to make payments under this section to the hospital class to which the provider belongs.

A joint house resolution (2021 TX H.J.R. 16 (NS)), which was introduced in a special session, proposes a constitutional amendment
calling for the Medicaid expansion for 'all persons who apply for that assistance and for whom federal matching funds are available
under the Patient Protection and Affordable Care Act[.]"

Also introduced in a special session, 2021 TX S.B. 41 (NS) would call for a Medicaid expansion-type program through a Section 1115
waiver. The goal of the program, Live Well Texas, would be 'to provide primary and preventative health care through high deductible
program health benefit plans to eligible individuals."Any proposed waiver would be designed to provide coverage, improve outcomes,
create incentives to transition from medical assistance to stable employment, promote personal responsibility and self-sufficiency, help
participants who become ineligible to transition to the private market, and leverage federal expansion funds, including the incentive
funds provided in the American Rescue Plan. The bill was introduced during the third special session. Similar bills in the House (2021
TX H.B. 3871 (NS)) and Senate (2021 TX S.B. 117 (NS)) did not fare well during the regular session.

A bill seeks to appropriate American Rescue Plan funds to extend post-partum coverage for an additional six month and to pay for
mental and behavioral health and substance use disorder services. The bill, 2021 TX H.B. 140 (NS), was introduced during the third
special session.

In Utah:

¢ Had it passed, 2021 UT H.B. 344 (NS) would have made a number of changes regarding Medicaid eligibility determinations.

Among other things, the bill would have allowed the Department of Health to contract with a third party vendor to verify eligibility;
require certain entities (the Office of Vital Records and Statistics, the Department of Corrections, a county jail, and the Department

of Workforce Services) to provide information about a change in a participant's circumstances that might affect Medicaid eligibility;
require the department to independently verify a determination by the Marketplace that an individual is eligible for Medicaid; direct

the department to seek a waiver from CMS allowing the department to suspend certain requirements for renewal (renewing eligibility
based on previously obtained information and using a pre-populated form); and direct the department to seek a waiver that would limit
hospital presumptive eligibility to pregnant women and children. The bill also set out how the department would have made eligibility
determinations during federally mandated maintenance-of-effort periods.

* A bill, 2021 UT H.B. 365 (NS), reorganizes certain functions of state government. Among other things, the bill merges the Department
of Health and the Department of Human Services into a single agency and moves certain aspects of the administration of Medicaid to
the Department of Workforce Services. The bill was adopted on March 23, 2021.

In Vermont:

Introduced on March 30, 2021, 2021 VT S.B. 132 (NS) would have consolidated authority for health reform innovation and added
certification requirements for accountable care organizations. The introduction to the bill explained what the bill aimed to do:

This bill proposes to consolidate responsibility for health care innovation under the Director of Health Care Reform in the Agency

of Human Services and to add new criteria to the certification requirements for accountable care organizations. It would require
accountable care organizations to collect, analyze, and report quality data to the Green Mountain Care Board to enable the Board to
determine value-based payment amounts and the appropriate distribution of shared savings among the accountable care organization's
participating health care providers. It would also require accountable care organizations to provide the Office of the Auditor of Accounts
with access to their records to enable the Auditor to audit their financial statements, receipt and use of federal and State monies,

and performance. . . . The bill would also require submission of reports to the General Assembly on health insurers' administrative
expenses, inclusion of specialty care in the All-Payer ACO Model, accountable care organizations' care coordination efforts, and the
likely impacts of requiring health insurance plans to offer at least two primary care visits per year without cost-sharing.

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The All-Payer ACO Model is a partnership program with CMS in which all major payers in the state (Medicare, Medicaid, and
commercial health insurers) work together under the same payment structure with a focus on high quality care, cost, and outcomes.

[FN303] The bill did not pass this session.
In Virginia:

The Health Department amended the administrative code, using the Fast-Track process, [FN304] +4 allow SNAP (Supplemental Nutrition
Assistance Program) income information for Medicaid eligibility determinations. The rule is published at 2021 VA REG TEXT 588803
(NS) (July 19, 2021).

Virginia adopted the Medicaid expansion in 2018. IFN305] The Department of Health, through the Fast-Track process, amended existing
regulatory provisions on hospital presumptive eligibility in order to incorporate changes made in the State Plan on account of the
expansion. Please see the notice at 2021 VA REG TEXT 534347 (NS) (July 19, 2021).

In Washington:

House Bill 1348 (2021 WA H.B. 1348 (NS)) will prohibit the state from suspending Medicaid eligibility for incarcerated individuals for
the first 29 days of incarceration. The bill will also allow incarcerated individuals to apply for Medicaid while incarcerated. The findings
supplied with the bill note that successful reentry of incarcerated individuals requires easy and early access to needed medical and
behavioral health care services upon release, and they also note that many incarcerations are 30 days or less. Governor Jay Inslee (D)
signed the bill on May 3, 2021.

The Health Care Authority gave notice of its intent to amend the State Plan to add home health social workers to the list of approved
home health providers. The notice is published at 2021 WA REG TEXT 588705 (NS) (July 3, 2021).

The Health Care Authority is seeking to amend the State Plan to increase reimbursements for individual providers, agency providers,
and adult family homes, and to raise the nursing facility budget dial and swing bed rates. Please see the notice published at 2021 WA
REG TEXT 588691 (NS) (July 21, 2021).

The Department of Social and Health Services amended existing administrative provisions to align the eligibility requirements of the

Roads to Community Living [FN306] demonstration with the eligibility requirements for Money Follows the Person. The notice is published
at 2021 WA REG TEXT 582934 (NS) (Oct. 6, 2021).

In West Virginia:

House Bill 2024 (2021 WV H.B. 2024 (NS)) has been adopted. The bill will make Medicaid payment for telehealth services on par with
the same services provided in person:

The Medicaid plan, which issues, renews, amends, or adjusts a plan, policy, contract, or agreement on or after July 1, 2021, shall
provide reimbursement for a telehealth service at a rate negotiated between the provider and the insurance company for virtual
telehealth encounters. The Medicaid plan, which issues, renews, amends, or adjusts a plan, policy, contract, or agreement on or after
July 1, 2021, shall provide reimbursement for a telehealth service for an established patient, or care rendered on a consulting basis to
a patient located in an acute care facility whether inpatient or outpatient on the same basis and at the same rate under a contract, plan,
agreement, or policy as if the service is provided through an in-person encounter rather than provided via telehealth.

Governor Jim Justice (R) signed the bill on April 9, 2021.
In Wisconsin:

If passed, 2021 WI S.B. 562 (NS) would extend Medicaid eligibility for post-partum women for a full year after birth. The bill was
introduced on September 15, 2021.

In Wyoming:

If passed in Wyoming, 2021 WY H.B. 162 (NS) would have directed that the governor, the state insurance commissioner, and the state
director of the Department of Health to collaborate with each other and with CMS to explore options for expanding Medicaid under the
Affordable Care Act. The bill provided, in part,

(b) If the collaboration required by subsection (a) of this section reveals viable and fiscally advantageous options as determined by the
governor for the expansion of Medicaid eligibility in Wyoming, the governor by and through the department of health is authorized to
pursue any Medicaid state plan amendments or other waivers that are necessary and prudent for the expansion.

Wyoming is one of just 11 states that have not adopted the expansion. [FN3°7] The bill did not pass before the legislature adjourned.

XVI. Additional Resources
The Families First Coronavirus Response Act (Families First Act), [FN308] 55 amended by the CARES Act, provided for a 6.2% increase

in the state FMAP (federal medical assistance percentage). However, the increased FMAP does not apply to all expenditures. A brief
from the Kaiser Family Foundation delves deeper into the requirements for the increased FMAP. [FN309] Additionally, the Families First

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Act paved the way for Medicaid funding of COVID-19 testing for uninsured individuals. A second Kaiser brief addresses questions
about that new eligibility option. [FNS10] Finally, CMS approved its first Section 1115 waiver in connection with the COVID-19 emergency
for the state of Washington. Kaiser published a brief explaining more about that waiver and what it may mean for other states. [FNS11]

XVII. Conclusion

In a dramatic defeat, Congressional attempts to repeal and replace the Affordable Care Act failed in the summer of 2017. The latest
attempt to challenge the law in the judicial branch failed as well in the summer of 2021, so for now, attention has moved away from
eliminating the Affordable Care Act. Still, the Trump Administration made its mark on the Medicaid program through the waivers it
granted. It remains to be seen how Trump-era waiver policies will be viewed under the Biden Administration, but we have already seen
some of those waiver policies reversed. Moreover, President Biden's January 21, 2021 executive order expressed disapproval for any
policies that would have the effect of limiting Medicaid.

The COVID-19 pandemic has required many temporary changes to Medicaid policy, and some states have indicated that they wish to
make some of those changes permanent, especially those relating to telehealth. We will continue to report on those as they are issued,
and when the emergency period ends, we will report on the transition to pre-COVID-19 policy.

© Copyright Thomson/West - NETSCAN's Health Policy Tracking Service

 

[FN2]

. "Executive Order on Strengthening Medicaid and the Affordable Care Act," The Whitehouse, Jan. 28, 2021, available at: https://
www.whitehouse.gov/briefing-room/presidential-actions/202 1/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-
care-act/.

[FN3]

. Melissa Quinn, "Biden Signs Executive Actions on Abortion Policy, Health Care Access," CBS News, Jan. 29, 2021, available at:
https:/Avww.cbsnews.com/news/biden-signs-health-care-access-executive-orders/.

[FN4]
. Texas v. United States, Case nos. 19-840 and 19-1019, June 17, 2021, available at: https:/Awww.supremecourt.gov/
opinions/20pdf/19-840_6jfm.pdf.

[FN5]

. Texas v. United States, Case nos. 19-840 and 19-1019, June 17, 2021, available at: https:/Awww.supremecourt.gov/
opinions/20pdf/19-840_6jfm.pdf.

[FN6]

. For an excellent discussion of the major events in this case, please see "Texas v. United States," Constitutional Accountability Center,
https:/Avww.theusconstitution.org/litigation/texas-v-united-states/.

[FN7]

. Adam Liptak, "Affordable Care Act Survives Latest Supreme Court Challenge," The New York Times, June 17, 2021, available at:
https:/Avww.nytimes.com/2021/06/17/us/obamacare-supreme-court.html.

[FN8]

. Press Release, "Statement by HHS Secretary Xavier Becerra on U.S. Supreme Court Decision to Uphold the Affordable Care Act in
California v. Texas," HHS, June 17, 2021, available at: https:/Avww.hhs.gov/about/news/2021/06/17/statement-hhs-secretary-xavier-
becerra-us-supreme-court-decision-uphold-affordable-care-act-california-texas.html.

[FN]

. Press Release, "New HHS Data Show More Americans than Ever Have Health Coverage through the Affordable Care Act," HHS,
June 5, 2021, available at: https:/Awww.hhs.gov/about/news/2021/06/05/new-hhs-data-show-more-americans-than-ever-have-health-
coverage-through-affordable-care-act.html#..

[FN10]

. In Maine, the expansion was decided upon by a ballot initiative in 2017. However, former Governor Paul LePage (R) refused to submit
the required State Plan amendment (SPA), so the expansion was not implemented.10After litigation, he submitted the SPA but also

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wrote to CMS requesting that the agency deny it. The state now has a new governor who favors the expansion, and she signed an
executive order shortly after taking office calling for the state to implement the expansion.10

[FN11]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated Aug. 12, 2021, available
at: https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN12]

. Erik Neumann, "Utah Voters Approved Medicaid Expansion, But State Lawmakers Are Balking," NPR, Feb. 8, 2019, available at:
https:/Avww.npr.org/sections/health-shots/201 9/02/08/692567463/utah-voters-approved-medicaid-expansion-but-state-lawmakers-are-
balking.

[FN13]

. Sean Moody, "Utah House Passes Senate Bill 96, While Crowd Protests Outside," KSL TV, Feb. 8, 2019, available at: https://
ksltv.com/407828/utah-lawmakers-pass-medicaid-expansion-changes/.

[FN14]

. 'Utah Becomes 1st State to get CMS' Approval for Partial Medicaid Expansion," Advisory Board, Apr. 1, 2019, available at: https://
www.advisory.com/daily-briefing/201 9/04/01 /utah-waiver.

[FN15]
. FMAP is a state's federal medical assistance percentage, often called the "match rate."Utah's FMAP is roughly 70%. See "Federal
Medical Assistance Percentage (FMAP) for Medicaid and Multiplier," Kaiser Family Foundation, available at: https:/Awww.kff.org/
medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTimeframe=1 &sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.
[FN16]

. Susan L. Hayes, ef al., "The Fiscal Case for Medicaid Expansion," Commonwealth Fund, Feb.15, 2019, available at: https://
www.commonwealthfund.org/blog/201 9/fiscal-case-medicaid-expansion.

[FN17]

. Harris Meyer, "Utah Pitches Medicaid Spending Cap to CMS," Modern Healthcare, May 31, 2019, available at: https://
www.modernhealthcare.com/payment/utah-pitches-medicaid-spending-cap-cms.

[FN18]

. Press Release, "CMS Statement on Partial Medicaid Expansion Policy," CMS, July 29, 2019, available at: https:/Avwww.cms.gov/
newsroom/press-releases/cms-statement-partial-medicaid-expansion-policy.

[FN19]

. 'Utah Section 1115 Demonstration Application Per Capita Cap," utah.gov, available at: https://medicaid.utah.gov/Documents/pdfs/
Utah1#115D#emonstrationApplication-P#erC#apitaC#ap-3#1May2019.pdf.

[FN20]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated Nov. 19, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

[FN21]

. See Grant Schulte, "Nebraska's Medicaid Expansion could Take another 18 Months," AP, Apr. 1, 2019, available at: https://
www.apnews.com/9d2ef5d739c8493b89898dcbec33e208; Martha Stoddard, "Nebraska's Medicaid Expansion Plan won't Start until
Late 2020, has Two Tiers of Coverage," Live Well Nebraska, Apr. 2, 2019, available at: https:/Avww.Nebraska's Medicaid expansion
plan won't start until late 2020, has two tiers of coverageomaha.com/livewellnebraska/nebraska-s-medicaid-expansion-plan-won-t-
start-until-late/article_1e80c01d-ddc7-5d98-870c-063cd2073283.html; Louise Norris, "Nebraska and the ACA's Medicaid Expansion,"
HealthInsurance.org, June 23, 2019, available at: https:/Awww.healthinsurance.org/nebraska-medicaid/.

[FN22]

. Letter from HHS to Nebraska Medicaid, Oct. 20, 2020, available at: https:/Avww.medicaid.gov/medicaid/section-1 115-demonstrations/
downloads/ne-hha-ca. pdf.

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[FN23]

. 'Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated Nov. 19, 2021, 2020, available
at: https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN24]

. Akeiisa Coleman, et al., "Medicaid Expansion Across the Country: A Check-In on Recent Ballot Initiatives," Commonwealth Fund,
Feb. 25, 2019, available at: https:/Avww.commonwealthfund.org/blog/201 9/medicaid-expansion-across-country-check-recent-ballot-
initiatives.

[FN25]

. Corin Cates-Camey, "Governor Signs Montana Medicaid Expansion Renewal Bill," Montana Public Radio, May 9, 2019, available at:
https:/Avww.mtpr.org/post/governor-signs-montana-medicaid-expansion-renewal-bill.

[FN26]

. 'Montana's Medicaid Expansion work requirements won't take effect Jan. 1," Missoula Current, Nov. 15, 2019, available at: https://
missoulacurrent.com/business/201 9/1 1/montana-medicaid-expansion-7/.

[FN27]

. 'Montana Section 1115 Health Economic Livelihood Partnership (Help) Amendment Application," July 2,
2021, Department of Public Health and Human Services, available at: https://dphhs.mt.gov/assets/waivers/
Montana' 115HELPAmendmenitFullPublicNotice-2-21.pdf.

[FN28]

. Andrea Halland, "Feds to Nix Work Requirements in Montana Medicaid Expansion Program," Kaiser Health News, Aug. 5, 2021,
available at: https://khn.org/news/article/feds-to-nix-work-requirements-in-montana-medicaid-expansion-program.

[FN29]

. Audrey Dutton, "Idaho Gov. Little Signs Bill to put Work Requirements on Medicaid Expansion," Idaho Statesmen, Apr. 9, 2019,
available at: https:/Awww.idahostatesman.com/news/politics-government/state-politics/article229018249.html.

[FN30]

. "Status of State Medicaid Expansion Decisions: Interactive Map," Kaiser Family Foundation, updated Nov. 19, 2021, available at:
https:/Avww.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/; Louise Norris, "Idaho and the
ACA's Medicaid Expansion," HealthInsurance.org, Nov. 26, 2019, available at: https:/Avww.healthinsurance.org/idaho-medicaid/.

[FN31]

. Akeiisa Coleman, ef a/., "Medicaid Expansion Across the Country: A Check-In on Recent Ballot Initiatives," Commonwealth Fund,
Feb. 25, 2019, available at: https:/Avww.commonwealthfund.org/blog/201 9/medicaid-expansion-across-country-check-recent-ballot-
initiatives.

[FN32]

. Izaak Anderson, "Idaho Medicaid Expansion Signups Pass 60,000," Idaho News 6, Jan. 27, 2020, available at: https://Awww.kivitv.com/
news/idaho-medicaid-expansion-signups-pass-60-000.

[FN33]

. Keith Ridler (Assoc. Press), "Idaho Medicaid Expansion Signups Lower than Expected since November Launch," Idaho Statesman,
Dec. 31, 2019, available at: https:/Avww.idahostatesman.com/news/politics-government/state-politics/article238877643.html.

[FN34]

. Keith Ridler (Associated Press), "Idaho Medicaid Expansion Numbers Continue to Rise," U.S. News and World Report, June 12, 2020,
available at: https:/Awww.usnews.com/news/best-states/idaho/articles/2020-06-1 2/idaho-medicaid-expansion-numbers-continue-to-
rise#:?:text=BOISE#Idaho(#AP)S#%om ,coverage#s#tatedfficialss#aidF#riday.

[FN35]

. Joe Parris, "They didn't Want the People of Idaho to Use the Process': Idaho Supreme Court Set To Review New Ballot Initiative
Law Amid Controversy," KTVB7, June 8, 2021, available at: https:/Awww.ktvb.com/article/news/local/208/idaho-supreme-court-voter-
initiative-bill-hearing/27 7-4fd65960-beaa-46c5-87a4-b67f0ec4d4aa.

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[FN36]

. Rebecca Boone, "Idaho Supreme Court Overturns Tougher Ballot Initiative Law," AP New, Aug. 23, 2021, available at: https://
apnews.com/article/courts-laws-idaho-idaho-supreme-court-b1a4a44deb5a0e490c4cfbac7f9a5c06.

[FN37]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated Nov. 19, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?.

[FN38]

. Rebecca Pifer, "Citing Lack of Funding, Oklahoma Withdraws Planned July 1 Medicaid Expansion," Healthcare Dive, June 1,
2020, available at: https:/Avww.healthcaredive.com/news/citing-lack-of-funding-oklahoma-withdraws-planned-july-1-medicaid-
expansio/578875/.

[FN39]

. See, e.g., Max Greenwood, "Oklahoma Voters Narrowly Approve Medicaid Expansion," The Hill, July 1, 2020, available at: https://
thehill.com/policy/healthcare/505368-oklahoma-voters-narrowly-approve-medicaid-expansion; Tami Luhby, "Voters in Deep-Red
Oklahoma Approve Medicaid Expansion under Obamacare," CNN, July 1, 2020, available at: https:/Awww.cnn.com/2020/06/30/politics/
oklahoma-medicaid-expansion/index.html.

[FN40]

. 'Oklahoma State Question 802, Medicaid Expansion Initiative (June 2020)," Ballotpedia, available at: https://ballotpedia.org/
Oklahoma_State_Question_802, Medicaid_Expansion_Initiative_(June_2020).

[FN41]

. "Oklahoma State Question 802, Medicaid Expansion Initiative (June 2020)," Ballotpedia, available at: https://ballotpedia.org/
Oklahoma_State_Question_802, Medicaid_Expansion_Initiative_(June_2020).

[FN42]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 7, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?.

[FN43]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated Nov. 19, 2021, available
at: https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'##note-18.

[FN44]

. See Dana Branham, "What Does Oklahoma's Medicaid Expansion Mean for Me? Who's Eligible and How to Apply," The Oklahoman,
June 14, 2021, available at: https:/Awww.oklahoman.com/story/news/202 1/06/01 /oklahoma-medicaid-expansion-june-1-how-apply-
eligible-changes/5254228001/; Press Release, "Oklahoma's Medicaid Expansion Will Provide Access to Coverage for 190,000
Oklahomans," CMS, July 1, 2021, available at: https:/Awww.cms.gov/newsroom/press-releases/oklahomas-medicaid-expansion-will-
provide-access-coverage-190000-oklahomans.

[FN45]

. Press Release, "Oklahoma's Medicaid Expansion Will Provide Access to Coverage for 190,000 Oklahomans," CMS, July 1, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/oklahomas-medicaid-expansion-will-provide-access-coverage- 190000-
oklahomans.

[FN46]

. Press Release, "Oklahoma's Medicaid Expansion Will Provide Access to Coverage for 190,000 Oklahomans," CMS, July 1, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/oklahomas-medicaid-expansion-will-provide-access-coverage- 1 90000-
oklahomans.

[FN47]

. Alex Smith, "Missouri Voters Approve Medicaid Expansion Despite Resistance From Republican Leaders," NPR, Aug. 5, 2020,
available at: https:/Awww.npr.org/sections/health-shots/2020/08/05/898899246/missouri-voters-approve-medicaid-expansion-despite-
resistance-from-republican-le.

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[FN48]

. Louise Norris, "Missouri and the ACA's Medicaid Expansion," healthinsurance.org, Aug. 4, 2020, available at: https://
www.healthinsurance.org/missouri-medicaid/.

[FN49]

. Doyle et al. v. Tidball, Missouri Supreme Court, No. SC99185, July 22, 2021, available at: https:/Awww.courts.mo.gov/file.jsp?
id=178955.

[FN50]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, Nov. 19, 2021, available at:
https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN51]

. News Release, "Missouri Medicaid Expansion Brings Quality Essential Health Coverage to More than 275,000 Missourians," HHS,
Oct. 4, 2021, available at: https:/Avww.hhs.gov/about/news/2021/10/04/missouri-medicaid-expansion-brings-quality-essential-health-
coverage.html?utm.

[FN52]

. News Release, "Missouri Medicaid Expansion Brings Quality Essential Health Coverage to More than 275,000 Missourians," HHS,
Oct. 4, 2021, available at: https:/Avww.hhs.gov/about/news/2021/10/04/missouri-medicaid-expansion-brings-quality-essential-health-
coverage.html?utm.

[FN53]

. "Medicaid Expansion in Arkansas: A Timeline," ACHI Blog, Apr. 22, 2021, available at: https://achi.net/newsroom/medicaid-expansion-
in-arkansas-a-timeline/; Status of State Action on the Medicaid Expansion Decision, Kaiser Family Foundation, updated Nov. 19, 2021,
available at: https:/Awww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?.

[FN54]

. Status of State Action on the Medicaid Expansion Decision, Kaiser Family Foundation, updated Nov. 19, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?.

[FN55]
. FMAP is the Federal Medical Assistance Percentage, or the match rate.

[FN56]

. Tara Straw, et ai/., "Health Provisions in American Rescue Plan Act Improve Access to Health Coverage During COVID Crisis," Center
on Budget and Policy Priorities, Mar. 11, 2021, available at: https://www.cbpp.org/research/health/health-provisions-in-american-
rescue-plan-act-improve-access-to-health-coverage.

[FN57]

. The brief makes estimates for 14 non-adopting states. This is because Missouri and Oklahoma, which had successful ballot measures
adopting the expansion, have not yet implemented it.

[FN58]

. Leighton Ku and Erin Brantley, "The Economic and Employment Effects of Medicaid Expansion under the American Rescue Plan,"
The Commonwealth Fund, May 20, 2021, available at: https:/Avww.commonwealthfund.org/publications/issue-briefs/2021/may/
economic-employment-effects-medicaid-expansion-under-arp?utm_source=alert&utm_medium=email&utm_campaign=Medicaid.

[FN59]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges.pdf.

[FN60]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

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[FN61]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN62]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN63]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN64]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN65]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN66]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN67]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges.pdf. (Footnote omitted; emphasis in original.)

[FN68]

. Kathleen Gifford, et a/., "States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address
Long-Standing Issues," Kaiser Family Foundation, Oct. 2021, available at: https://files.kff.org/attachment/Report-States-Respond-to-
COVID-19-Challenges. pdf.

[FN69]

. MaryBeth Musumeci, "Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,"
Kaiser Family Foundation, Sept. 20, 2018, available at: https:/Avww.kff.org/medicaid/issue-brief/section-1 115-medicaid-demonstration-
waivers-the-current-landscape-of-approved-and-pending-waivers/?utm_campaign=KFF-2018-The-Latest&utm_source=.

[FN70]

. Press Release, "CMS Announces New Policy Guidance for States to Test Community Engagement for Able-Bodied Adults,"

CMS, Jan. 11, 2018, available at: https:/Awww.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/201 8-Press-releases-
items/2018-01-11.html; State Medicaid Director Letter, SMD #18-002, Jan. 11, 2018, available at: https:/Awww.medicaid.gov/federal-
policy-guidance/downloads/smd18002. pdf.

[FN71]

. "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Mar. 18, 2021,
available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 1 15-waivers-by-state/.

[FN72]

. "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Apr. 16, 2021,
available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 1 15-waivers-by-state/.

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[FN73]

. "Medicaid Waiver Tracker," Kaiser Family Foundation, updated Aug. 16, 2021, available at: https:/Avww.kff.org/medicaid/issue-brief/
medicaid-waiver-tracker-approved-and-pending-section-1 115-waivers-by-state/.

[FN74]

. "Medicaid Waiver Tracker," Kaiser Family Foundation, updated Aug. 16, 2021, available at: https:/Avww.kff.org/medicaid/issue-brief/
medicaid-waiver-tracker-approved-and-pending-section-1 115-waivers-by-state/.

[FN75]

. "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Apr. 16, 2021,
available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 1 15-waivers-by-state/.

[FN76]

. Sara Rosenbaum, "Biden Administration Begins Process of Rolling Back Approval for Medicaid Work

Experiments, But Supreme Courts Hangs On," Commonwealth Fund Blog, Apr. 8, 2021, available at: https://
www.commonwealthfund.org/blog/2021/biden-administration-begins-process-rolling-back-approval-medicaid-work-experiments?
utm_source=alert&utm_medium=email&utm_campaign=Medicaid.

[FN77]
. https:/Awww.supremecourt.gov/search.aspx?filename=/docket/docketfiles/html/public/20-37.html.

[FN78]

. Alexandra Jaffe, "Biden Administration to undo Medicaid Work Requirements," Associated Press, Feb. 12, 2021, available at: https://
apnews.com/article/politics-medicaid-coronavirus-pandemic-16f7d6600ee9f240b63e8a5bdfa90276

[FN79]

. "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Aug. 21, 2019,
available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 1 15-waivers-by-state/.

[FN80]

. Letter from HHS to Texas Medicaid Director, Apr. 16, 2021, available at: https:/Awww.medicaid.gov/medicaid/section-1115-
demonstrations/downloads/tx-healthcare-transformation-ca. pdf.

[FN81]

. Letter from HHS to Texas Medicaid Director, Apr. 16, 2021, available at: https://www.medicaid.gov/medicaid/section-1115-
demonstrations/downloads/tx-healthcare-transformation-ca.pdf.

[FN82]

. Letter from HHS to Texas Medicaid Director, Apr. 16, 2021, available at: https:/Awww.medicaid.gov/medicaid/section-1115-
demonstrations/downloads/tx-healthcare-transformation-ca. pdf.

[FN83]

. Texas is one of just 12 states that have not adopted the Medicaid expansion. See "Status of State Action on the Medicaid Expansion
Decision," Kaiser Family Foundation, updated Apr. 13, 2021, available at: https:/Awww.kff.org/health-reform/state-indicator/state-activity-
around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=#c#olld:#L#ocation #s#ort:#asc'#.

[FN84]

. Sources name Texas as the state with the highest, or one of the highest, uninsured rates in the country, at roughly 29%.
See, e.g., Ayla Ellison, "States Ranked by Uninsured Rates," Becker's Hospital Review, July 15, 2020, available at: https://
www.beckershospitalreview.com/rankings-and-ratings/states-ranked-by-uninsured-rates.html.

[FN85]

. Jeremy Blackman, "Biden Administration Rescinds Billions in Medicaid Funding for Texas," Houston Chronicle, Apr. 16, 2021,
available at: https:/Awww.houstonchronicle.com/politics/texas/article/Biden-administration-rescinds-billions-in-16107275.php.

[FN86]

. Jeremy Blackman, "Biden Administration Rescinds Billions in Medicaid Funding for Texas," Houston Chronicle, Apr. 16, 2021,
available at: https:/Awww.houstonchronicle.com/politics/texas/article/Biden-administration-rescinds-billions-in-16107275.php.

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[FN87]

. Jeremy Blackman, "Biden Administration Rescinds Billions in Medicaid Funding for Texas," Houston Chronicle, Apr. 16, 2021,
available at: https:/Awww.houstonchronicle.com/politics/texas/article/Biden-administration-rescinds-billions-in-16107275.php.

[FN88]

. Morgan Haefner, "Revoked Texas Medicaid Waiver Credit Negative for Hospitals," Becker's Hospital Review, Apr. 27, 2021, available
at: https:/Avwww.beckershospitalreview.com/finance/revoked-texas-medicaid-waiver-credit-negative-for-hospitals.html.

[FN89]

. Fact Sheet, "Health Adult Opportunity Fact Sheet," CMS, Jan. 30, 2020, available at: https:/Avww.cms.gov/newsroom/fact-sheets/
healthy-adult-opportunity.

[FN90]

. Fact Sheet, "Health Adult Opportunity Fact Sheet," CMS, Jan. 30, 2020, available at: https:/Avww.cms.gov/newsroom/fact-sheets/
healthy-adult-opportunity.

[FN91]

. Fact Sheet, "Health Adult Opportunity Fact Sheet," CMS, Jan. 30, 2020, available at: https:/Avww.cms.gov/newsroom/fact-sheets/
healthy-adult-opportunity; State Medicaid Director Letter, Healthy Adult Opportunity, SMD #20-001, Jan. 30, 2020, available at: https://
www.medicaid.gov/sites/default/files/F ederal-Policy-Guidance/Downloads/smd20001.pdf.

[FN92]

. Press Release, "Trump Administration Announces Transformative Medicaid Healthy Adult Opportunity," CMS, Jan. 30, 2020, available
at: https:/Avww.cms.gov/newsroom/press-releases/trum-administration-announces-transformative-medicaid-healthy-adult-opportunity.

[FN93]

. Dan Diamond and Rachel Roubein, "Block Grants' No More: Trump's Medicaid Overhaul has New Name, Same Goals," Politico, Jan.
29, 2020, available at: https:/Avww.politico.com/news/2020/0 1/29/trump-medicaid-overhaul-block-grants-108882.

[FN94]

. Dan Diamond and Rachel Roubein, "Block Grants' No More: Trump's Medicaid Overhaul has New Name, Same Goals," Politico, Jan.
29, 2020, available at: https:/Avww. politico.com/news/2020/0 1/29/trump-medicaid-overhaul-block-grants-108882.

[FN95]

. Robin Rudowitz, et al., "Implications of CMS's New "Healthy Adult Opportunity" Demonstrations for Medicaid," Kaiser Family
Foundation, Feb. 5, 2020, available at: https:/Awww.kff.org/medicaid/issue-brief/implications-of-cmss-new-healthy-adult-opportunity-
demonstrations-for-medicaid/.

[FN96]

. Gregory Craig, "Medicaid Healthy Adult Opportunity ? or Block Grants by Another Name," American Nurse's Association's Capitol
Beat, Feb. 27, 2020, available at: https://anacapitolbeat.org/2020/02/27/medicaid-healthy-adult-opportunity-or-block-grants-by-another-
name/.

[FN97]

. Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 7, 2021, available at:
https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#

[FN98]

. 'Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier," FY 2021, Kaiser Family
Foundation, available at: https:/Avww.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FNg9]

. Ross Margulies, "CMS Approves Tennessee "Block Grant" Waiver: A Summary and Analysis from your Editors," JDSupra, Jan. 11,
2021, available at: https:/Awww.jdsupra.com/legalnews/cms-approves-tennessee-block-grant-8012077/.

[FN100]

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. Press Release, "CMS Approves Innovative Tennessee Aggregate Cap Demonstration to Prioritize Accountability for Value and
Outcomes," CMS, Jan. 8, 2021, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-approves-innovative-tennessee-
aggregate-cap-demonstration-prioritize-accountability-value-and; Ross Margulies, "CMS Approves Tennessee "Block Grant" Waiver:
A Summary and Analysis from your Editors," JDSupra, Jan. 11, 2021, available at: https:/Awww.jdsupra.com/legalnews/cms-approves-
tennessee-block-grant-8012077/..

[FN101]

. Phil Galewitz, "Trump Administration Approves First Medicaid Block Grant, in Tennessee," Kaiser Health News, Jan. 8, 2021,
available at: https://khn.org/news/article/truamp-administration-approves-first-medicaid-block-grant-in-tennessee/?utm; Ross Margulies,
"CMS Approves Tennessee ?Block Grant' Waiver: A Summary and Analysis from your Editors," JDSupra, Jan. 11, 2021, available at:
https:/Avww.jdsupra.com/legalnews/cms-approves-tennessee-block-grant-8012077/.

[FN102]

. Ross Margulies, "CMS Approves Tennessee ?Block Grant' Waiver: A Summary and Analysis from your Editors," JDSupra, Jan. 11,
2021, available at: https:/Avww.jdsupra.com/legalnews/cms-approves-tennessee-block-grant-8012077/.

[FN103]

. Timothy Jost, "Health Care Litigation and the Biden Administration," Commonwealth Fund, Jan. 19, 2021, available at: https://
www.commonwealthfund.org/blog/2021/health-care-litigation-and-biden-administration?utm_source=alert&utm.

[FN104]

. "Status of State Action on Medicaid Expansion Decision," Kaiser Family Foundation, Nov. 2, 2020, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN105]

. Ross Margulies, "CMS Approves Tennessee ?Block Grant' Waiver: A Summary and Analysis from your Editors," JDSupra, Jan. 11,
2021, available at: https:/Avww.jdsupra.com/legalnews/cms-approves-tennessee-block-grant-8012077/, footnote 1.

[FN106]

. Kelsey Waddill, "How Biden's Executive Order May Impact Medicaid, ACA Marketplaces," HealthPayer Intelligence, Feb. 3, 2021,
available at: https://healthpayerintelligence.com/news/how-bidens-executive-order-may-impact-medicaid-aca-marketplaces.

[FN107]

. Vivian Jones, "Tennessee Democrats ask Biden Administration to Reverse Medicaid Block Grant Waiver," The Center Square,
Jan. 25, 2021, available at: htips:/Avww.thecentersquare.com/tennessee/tennessee-democrats-ask-biden-administration-to-reverse-
medicaid-block-grant-waiver/article_dc344406-5f62-11eb-a41e-7b0e2ac974d2. html.

[FN108]

. John Styf, "Tennessee's Medicaid Block Grant Waiver Challenged in Court," The Center Square, May 10, 2021, available at:
https:/Avww.thecentersquare.com/tennessee/tennessees-medicaid-block-grant-waiver-challenged-in-court/article_9b6f9b9e-
b1d5-11eb-9724-9f3426968b75.html.

[FN109]

. 'Health Homes,' Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/long-term-services-supports/health-homes/index.html;
'Health Homes (Section 2703) Frequently Asked Questions,' Medicaid.gov, available at: https://Awww.medicaid.gov/state-resource-
center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/health-homes-faq-5-3-12_2.pdf.

[FN110]

. 'State-by-State Health Home State Plan Amendment Matrix," CMS, updated Oct. 2021, available at: https:/Avww.medicaid.gov/state-
resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/state-hh-spa-at-a-glance-
matrix.pdf.

[FN111]

. 'Health Homes (1945 of SSA/ Section 2703 of ACA) Frequently Asked Questions Series II,' CMS, available at: https://
www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technical-assistance/downloads/health-
homes-section-2703-faq.pdf.

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[FN112]
. Please see the Health Home Resource Center, available at: https:/Awww.medicaid.gov/State-Resource-Center/Medicaid-State-
Technical-Assistance/Health-Homes-Technical-Assistance/Health-Home-Information-Resource-Center.html.

[FN113]

. State Medicaid Director Letter #20-004, "Value-Based Care Opportunities in Medicaid," CMS, Sept. 15, 2020, available at: https://
www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd20004. pdf.

[FN114]

. Press Release, "CMS Issues New Roadmap for States to Accelerate Adoption of Value-Based Care to Improve Quality of Care for
Medicaid Beneficiaries," CMS, Sept. 15, 2020, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-issues-new-roadmap-
states-accelerate-adoption-value-based-care-improve-quality-care-medicaid.

[FN115]

. Fact Sheet, "Value-based Care State Medicaid Directors Letter," CMS, Sept. 15, 2020, available at: https:/Avwww.cms.gov/newsroom/
fact-sheets/value-based-care-state-medicaid-directors-letter.

[FN116]

. Press Release, "Trump Administration Approves Innovative State-Led Health Reform to Expand and Strengthen Coverage for
Georgia Residents," CMS. Oct. 15, 2020, available at: https:/Awww.cms.gov/newsroom/press-releases/trump-administration-approves-
innovative-state-led-health-reform-expand-and-strengthen-coverage.

[FN117]

. Press Release, "Trump Administration Approves Innovative State-Led Health Reform to Expand and Strengthen Coverage for
Georgia Residents," CMS. Oct. 15, 2020, available at: https:/Awww.cms.gov/newsroom/press-releases/trump-administration-approves-
innovative-state-led-health-reform-expand-and-strengthen-coverage.

[FN118]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 7, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act.

[FN119]

. Department of Health and Human Services Letter to Oklahoma's Chief State Medicaid Director, Dec. 22, 2020, available at: https://
www.medicaid.gov/medicaid/section-1 115-demonstrations/downloads/ok-imd-waiver-smi-sud-ca.pdf.

[FN120]

. Department of Health and Humans Services Letter to Maine's Director of MaineCare, Dec. 22, 2020, available at: https://

www. medicaid.gov/medicaid/section-1 115-demonstrations/downloads/me-sud-care-initiative-ca.pdf.

[FN121]

. Press Release, "CMS Announces Approval of Oklahoma & Maine's Substance Use Disorder Demonstrations, the 30th and 31st

to Expand Access to Combat the Opioid Crisis," Dec. 22, 2020, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-
announces-approval-oklahoma-maines-substance-use-disorder-demonstrations-30th-and-31st-expand. The press release announcing
the new process for SUD demonstrations is "CMS Announces new Medicaid Policy to Combat the Opioid Crisis by Increasing Access
to Treatment Options, CMS, Nov. 1, 2017, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-announces-new-medicaid-
policy-combat-opioid-crisis-increasing-access-treatment-options.

[FN122]

. Press Release, "CMS Announces New Medicaid Demonstration Opportunity to Expand Mental Health Treatment Services," CMS,
Nov. 13, 2018, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-announces-new-medicaid-demonstration-opportunity-
expand-mental-health-treatment-services.

[FN123]

. Press Release, "CMS Announces Approval of Oklahoma & Maine's Substance Use Disorder Demonstrations, the 30th and 31st
to Expand Access to Combat the Opioid Crisis," Dec. 22, 2020, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-
announces-approval-oklahoma-maines-substance-use-disorder-demonstrations-30th-and-31 st-expand.

[FN124]

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. 'Behavioral Health Integration," SAMHSA, available at: https:/Avww.samhsa.gov/sites/default/files/samhsa-behavioral-health-
integration.pdf.

[FN125]

. 'Behavioral Health Services,' Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/benefits/bhs/index.html.

[FN126]

. Julia Zur, et al., "Medicaid's Role in Financing Behavioral Health Services for Low-Income Individuals," Kaiser Family Foundation,
June 29, 2017, available at: https:/Avww.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-
income-individuals/.

[FN127]

. "Status of State Medicaid Expansion Decisions: Interactive Map," Kaiser Family Foundation, updated Mar. 12, 2021, available at:
https:/Avww.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[FN128]

. Press Release, "Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention," CMS, Sept. 7, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-harris-administration-awards-15-million-20-states-mobile-crisis-
intervention.

[FN129}

. Press Release, "Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention," CMS, Sept. 7, 2021,
available at: https://(www.cms.gov/newsroom/press-releases/biden-harris-administration-awards- 15-million-20-states-mobile-crisis-
intervention.

[FN130]

. Press Release, "Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention," CMS, Sept. 7, 2021,
available at: https:/Awww.cms.gov/newsroom/press-releases/biden-harris-administration-awards-15-million-20-states-mobile-crisis-
intervention.

[FN131]

. 'Medicaid's Role in Addressing the Opioid Epidemic,' Kaiser Family Foundation, updated June 3, 2019, available at: http:/Avww.kff.org/
infographic/medicaids-role-in-addressing-opioid-epidemic/.

[FN132]

. 'Drug Overdose Deaths in the U.S. Top 100,000 Annually," CDC, Nov. 17, 2021, available at: https:/Avww.cdc.gov/nchs/pressroom/
nchs_press_releases/2021/20211117.htm.

[FN133]

. 'Medicaid's Role in Addressing the Opioid Epidemic,' Kaiser Family Foundation, updated June 3, 2019, available at: http:/Avww.kff.org/
infographic/medicaids-role-in-addressing-opioid-epidemic/.

[FN134]

. CMS Opioid Misuse Strategy 2016, CMS, Jan. 5, 2017, available at: https:/Awww.cms.gov/Outreach-and-Education/Outreach/
Partnerships/Downloads/CMS-Opioid-Misuse-Strategy-2016.pdf.

[FN135]

. CMS Roadmap to Address the Opioid Epidemic, CMS, available at: https:/Awww.cms.gov/About-CMS/Agency-Information/Emergency/
Downloads/Opioid-epidemic-roadmap.pdf.

[FN136]

. Christine Vestal, 'This Obscure Medicaid Waiver Opens up More Beds for Opioid Treatment,' PBS, Stateline, Apr. 5, 2017, available
at: http:/Avww.pbs.org/newshour/rundown/obscure-medicaid-waiver-opens-beds-opioid-treatment/.

[FN137]

. According to the Kaiser Family Foundation, 33 states currently have such waivers and three states (Arizona, Massachusetts, and
Tennessee) have such a waiver pending. Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State, Kaiser

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Family Foundation, updated June 9, 2021, available at: https://Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-
pending-section-1115-waivers-by-state/.

[FN138]

. Anna Gorman, 'For Low-Income Drug Users, Medi-Cal Offers A Fresh Start,' Kaiser Health News, Sept. 8, 2017, available at: http://
khn.org/news/for-low-income-drug-users-medi-cal-offers-a-fresh-start/?utm_campaign=KFF-2017-The-Latest&utm.

[FN139]

. State Medicaid Director Letter, "Implementation of Section 5052 of the SUPPORT for Patients and Communities Act ? State Plan
Option under Section 1915(I) of the Social Security Act," SMD #19-003, Nov. 6, 2019, available at: https://Awww.medicaid.gov/federal-
policy-guidance/downloads/smd19003.pdf.

[FN140]

. "CMS and SAMHSA Announce New Participants of the Certified Community Behavioral Health Clinic Demonstration," Medicaid.gov,
Aug. 5, 2020, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/298ee1f.

[FN141]

. News Release, "HHS Selects Eight States for New Demonstration Program to Improve Access to High Quality Behavioral Health
Services," HHS, Dec. 21, 2016, available at: http:/Awayback.archive-it.org/3926/201 70128161256/hitps://www.hhs.gov/about/
news/2016/12/21/hhs-selects-eight-states-new-demonstration-program-improve-access-high-quality-behavioral-health.

[FN142]
. "CMS and SAMHSA Announce New Participants of the Certified Community Behavioral Health Clinic Demonstration," Medicaid.gov,
Aug. 5, 2020, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/bulletins/298ee1f.

[FN143]

. Press Release, "CMS Commits $50 Million to Assist States with Substance Use Disorder Treatment and Recovery," CMS, June 25,
2019, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-commits-50-million-assist-states-substance-use-disorder-
treatment-and-recovery.

[FN144]

. Press Release, "CMS Commits $50 Million to Assist States with Substance Use Disorder Treatment and Recovery," CMS, June 25,
2019, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-commits-50-million-assist-states-substance-use-disorder-
treatment-and-recovery.

[FN145]

. 'Demonstration Project to Increase Substance Use Provider Capacity," Medicaid.gov, available at: https:/Avww.medicaid.gov/
medicaid/benefits/behavioral-health-services/substance-use-disorder-prevention-promotes-opioid-recovery-and-treatment-for-patients-
and-communities-support-act-section-1003/index.html.

[FN146]

. "Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act:
Section 1003," Medicaid.gov, available at: htips:/Awww.medicaid.gov/medicaid/benefits/behavioral-health-services/substance-use-
disorder-prevention-promotes-opioid-recovery-and-treatment-for-patients-and-communities-support-act-section-1003/index.html.

[FN147]

. HHS email update, "Awards for the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT)
for Patients and Communities Act Section 1003 Demonstration Project to Increase Substance Use Provider Capacity under the
Medicaid Program," Sept. 17, 2021.

[FN148]

. The act defines a family-focused residential treatment program as "a trauma-informed residential program primarily for SUD treatment
for pregnant and postpartum women and parents and guardians that allows children to reside with such women or their parents

or guardians during treatment to the extent appropriate and applicable."Joint CMS ACF Guidance, "Support for Family-Focused
Residential Treatment-Title IV-E and Medicaid-Guidance," Oct. 5, 2020, available at: https:/Avww.medicaid.gov/federal-policy-guidance/
downloads/cib100520. pdf.

[FN149]

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. Joint CMS ACF Guidance, "Support for Family-Focused Residential Treatment-Title IV-E and Medicaid-Guidance," Oct. 5, 2020,
available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/cib100520.pdf.

[FN150]

. 'Best Practices for Designing and Implementing Substance Use Disorder (SUD)-Focused Health Homes," CMS, Dec. 2020, available
at: https:/Avwww.medicaid.gov/state-resource-center/downloads/best-practices-health-homes-support-act-section-1006a.pdf.

[FN151]
. CMCS is CMS' Center for Medicaid and CHIP Services.

[FN152]

. CMCS Informational Bulletin, "Guidance for States on the Availability of an Extension of the Enhanced Federal Medical Assistance
Percentage (FMAP) Period for Certain Medicaid Health Homes for Individuals with Substance Use Disorders (SUD)," May 7, 2019,
available at:https://www.medicaid.gov/federal-policy-guidance/downloads/cib0507 19. pdf.

[FN153]

. "CMS Reminds States of The SUPPORT Act Medicaid Medication Assisted Treatment (MAT) Services and Drugs Mandatory
Coverage Starting October 1st, Medicaid.gov, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/
bulletins/2a3b044.

[FN154]

. "CMS Reminds States of The SUPPORT Act Medicaid Medication Assisted Treatment (MAT) Services and Drugs Mandatory
Coverage Starting October 1st, Medicaid.gov, available at: https://content.govdelivery.com/accounts/USCMSMEDICAID/
bulletins/2a3b044.

[FN155]

. State Medicaid Director Letter, "Opportunities to Design Innovative Service Delivery Systems for Adults with a Serious Mental Illness
or Children with a Serious Emotional Disturbance," SMD #18-011, Nov. 13, 2018, available at: https:/Awww.medicaid.gov/federal-policy-
guidance/downloads/smd 1801 1.padf.

[FN156]

. Press Release, "CMS Announces Approval of Groundbreaking Demonstration to Expand Access to Behavioral Health Treatment,"
CMS, Nov. 6, 2019, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-announces-approval-groundbreaking-
demonstration-expand-access-behavioral-health-treatment.

[FN157]

. "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," Kaiser Family Foundation, updated Nov. 17, 2021,
2020, available at: https:/Awww.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1 115-waivers-by-
state/#note-3-1.

[FN158]

. LTSS Models, CMS, available at: https:/Awww.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-
Center/info/hcbs.

[FN159]

. 'Home- and Community-Based Services," MACPAC, available at: https:/Avww.macpac.gov/subtopic/home-and-community-based-
services/.

[FN160]

. 'Mandatory and Optional Benefits," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/benefits/mandatory-optional-
medicaid-benefits/index.html.

[FN164]
. See, e.g., "Waivers," MACPAC, available at: https:/Avww.macpac.gov/medicaid-101/waivers/.

[FN162]

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. Molly O'Malley Watts, et a/., "Medicaid Home and Community-Based Services Enrollment and Spending," Kaiser Family Foundation,
Feb. 4, 2020, available at: https:/Avww.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-
spending/.

[FN163]

. State Medicaid Director Letter, 'Community First Choice State Plan Option,' SMD #16-011, Dec. 30, 2016, available at: https://
www.medicaid.gov/federal-policy-guidance/downloads/smd1601 1 .pdf.

[FN164]

. Kathleen Gifford, et al., "A View from the States: Key Medicaid Policy Changes: Results from a 50-State Medicaid Budget Survey for
State Fiscal Years 2019 and 2020," Kaiser Family Foundation, Oct. 2019, available at: https://www.kff.org/medicaid/report/a-view-from-
the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-201 9-and-2020/.

[FN165]

. 'Home- and Community-Based Services 1915(c)," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/home-community-
based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html.

[FN166]

. MaryBeth Musumeci, ef a/., "Key State Policy Choices about Medicaid Home and Community-Based Services," Kaiser Family
Foundation, Feb. 4, 2021, available at: https:/Avww.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-
community-based-services/.

[FN167]

- "Bill to Expand Medicaid Home and Community Based Services Introduced in Congress," National Health Law Program, Mar. 16,
2021, available at: https://healthlaw.org/news/bill-to-expand-medicaid-home-and-community-based-services-introduced-in-congress/.

[FN168]

. Press Release, "Dingell, Hassan, Casey, Brown Release Draft Proposal for HCBS Access Act," Rep. Dingell's web site, Mar. 16,
2021, available at: https://debbiedingell.house.gov/news/documentsingle.aspx?7Document|D=2932.

[FN169]

. Press Release, "CMS Seeks Feedback on Performance of Medicaid Funded Home and Community-Based Services," CMS, Sept.
18, 2020, available at: https://www.cms.gov/newsroom/press-releases/cms-seeks-feedback-performance-medicaid-funded-home-and-
community-based-services.

[FN170]

. "Request for Information: Recommended Measure Set for Medicaid-Funded Home and Community-Based Services," CMS, Sept.
2020, available at: https:/Awww.medicaid.gov/medicaid/quality-of-care/downloads/rfi-hcbs-recommended-measure-set. pdf.

[FN171]

. Press Release, "CMS Releases Toolkit to Accelerate State Efforts to Rebalance Long-term Care Systems and Enhance Home and
Community-Based Services for Eligible Medicaid Beneficiaries," CMS, Nov. 2, 2020, available at: https:/Avww.cms.gov/newsroom/
press-releases/cms-releases-toolkit-accelerate-state-efforts-rebalance-long-term-care-systems-and-enhance-home-and.

[FN172]

. Press Release, "CMS Releases Toolkit to Accelerate State Efforts to Rebalance Long-term Care Systems and Enhance Home and
Community-Based Services for Eligible Medicaid Beneficiaries," CMS, Nov. 2, 2020, available at: https:/Avww.cms.gov/newsroom/
press-releases/cms-releases-toolkit-accelerate-state-efforts-rebalance-long-term-care-systems-and-enhance-home-and.

[FN173]

. Fact Sheet, "Long-term Services and Supports (LTSS) Rebalancing Toolkit Fact Sheet," CMS, Nov. 2, 2020, available at: https://
www.cms.gov/newsroom/fact-sheets/long-term-services-and-supports-ltss-rebalancing-toolkit-fact-sheet.

[FN174]

. 'Long-Term Services and Supports Rebalancing Toolkit," Medicaid.gov, Nov. 2020, available at: https://www.medicaid.gov/medicaid/
long-term-services-supports/downloads/ltss-rebalancing-toolkit.pdf.

[FN175]

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. Fact Sheet, "Long-term Services and Supports (LTSS) Rebalancing Toolkit Fact Sheet," CMS, Nov. 2, 2020, available at: https://
www.cms.gov/newsroom/fact-sheets/long-term-services-and-supports-ltss-rebalancing-toolkit-fact-sheet.
[FN176]

. The web page is available at: https:/Avww.medicaid.gov/medicaid/nome-community-based-services/guidance/strengthening-and-
investing-home-and-community-based-services-for-medicaid-beneficiaries-american-rescue-plan-act-of-2021-section-9817-spending-
plans-and-narratives/index.html.

[FN177]

. Press Release, "CMS Launches Webpage to Share Innovative State Actions to Expand Medicaid Home and Community-based
Services," CMS, Oct. 21, 2021, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-launches-webpage-share-innovative-
state-actions-expand-medicaid-home-and-community-based.

[FN178]

. Press Release, "CMS Launches Webpage to Share Innovative State Actions to Expand Medicaid Home and Community-based
Services," CMS, Oct. 21, 2021, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-launches-webpage-share-innovative-
state-actions-expand-medicaid-home-and-community-based.

[FN179]

. "Fact Sheet: Summary of Key Provisions of the Home and Community-Based Services (HCBS) Settings Final Rule (CMS 2249-
F/2296-F)," CMS, Jan. 10, 2014, available at: https:/Avww.medicaid.gov/sites/default/files/201 9-12/hcbs-setting-fact-sheet. pdf.

[FN180]
. 79 F.R. 2948-01 (Jan. 16, 2014).

[FN181]

. CMCS Informational Bulletin, 'Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria,' May
9, 2017, available at: https://Awww.medicaid.gov/federal-policy-guidance/downloads/cib050917.pdf.

[FN182]

. State Medicaid Director Letter #20-003, "Home and Community-Based Settings Regulation ? Implementation Timeline Extension
and Revised Frequently Asked Questions," CMS, July 14, 2020, available at: https:/Avww.medicaid.gov/Federal-Policy-Guidance/
Downloads/smd20003.pdf.

[FN183]

. CMCS Informational Bulletin, "Extension of the Spousal Impoverishment Rules for Married Applicants and Recipients of Home
and Community-Based Services," CMS, May 4, 2021, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/
cib050421 .pdf.

[FN184]

. 2021 FD H.B. 1717 (NS).

[FN185]

. Dear Medicaid Director Letter, "Implementation of American Rescue Plan Act of 2021 Section 9817: Additional Support for
Medicaid Home and Community-Based Services during the COVID-19 Emergency," #21-003, May 13, 2021, available at: https://
www.medicaid.gov/federal-policy-guidance/downloads/smd21003.pdf.

[FN 186]

. Elizabeth Williams and MaryBeth Musumeci, "Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access,"
Kaiser Family Foundation, Oct. 4, 2021, available at: https:/Awww.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-
coverage-affordability-and-hcbs-access/?utm_.

[FN187]

. Priya Chidambaram and MaryBeth Musumeci, "Potential Impact of Additional Federal Funds for Medicaid HCBS for Seniors

and People with Disabilities," May 28, 2021, available at: https://Awww.kff.org/medicaid/issue-brief/potential-impact-of-additional-
federal-funds-for-medicaid-hcbs-for-seniors-and-people-with-disabilities/; State Medicaid Director Letter, "Implementation of
American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid Home and Community-Based Services during the

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COVID-19 Emergency," SMD #21-03, CMS, May 13, 2021, available at: https:/Awww-.medicaid.gov/federal-policy-guidance/downloads/
smd21003.pdf.

[FN188]

. MaryBeth Musumeci, ef a/., "State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19," Aug. 26,
2020, available at: https:/Awww.kff.org/medicaid/issue-brief/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-
covid-19/.

[FN189]

. Elizabeth Williams and MaryBeth Musumeci, "Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access,"
Kaiser Family Foundation, Oct. 4, 2021, available at: https:/Awww.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-
coverage-affordability-and-hcbs-access/?utm_.

[FN190]

. Elizabeth Williams and MaryBeth Musumeci, "Children with Special Health Care Needs: Coverage, Affordability, and HCBS Access,"
Kaiser Family Foundation, Oct. 4, 2021, available at: https:/Awww.kff.org/medicaid/issue-brief/children-with-special-health-care-needs-
coverage-affordability-and-hcbs-access/?utm_.

[FN191]

. News Release, 'HHS Announces new Affordable Care Act Options for Community-Based Care,' Apr. 26, 2012, available at: http://
www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2012-Press-Releases-ltems/2012-04-26.html.

[FN192]

. Report to Congress, Community First Choice: Interim Report to Congress by HHS Secretary Kathleen Sebelius, 2014, available at:
http://www. medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-
Based-Services/Downloads/Community-First-Choice-Interim-Report-to-Congress. pdf.

[FN193]

- 'Community First Choice (CFC) 1915(k)," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/hcbs/downloads/community-
first-choice-interim-report-to-congress. pdf.

[FN194]
. Program of All-Inclusive Care for the Elderly, CMS, available at: https:/Avww.medicaid.gov/medicaid/ltss/pace/index.html.

[FN195]
. Program of All-Inclusive Care for the Elderly, CMS, available at: https:/Avwww.medicaid.gov/medicaid/Itss/pace/index.html.

[FN196]

. Fact Sheet, "Programs of All-Inclusive Care for the Elderly (PACE) Final Rule (CMS-4168-F)," CMS, May 28, 2019, available at:
https:/Avww.cms.gov/newsroom/fact-sheets/programs-all-inclusive-care-elderly-pace-final-rule-cms-4168-f.

[FN197]

. "Medicaid's Money Follows the Person Rebalancing Demonstration Program," Congressional Research Services, May 26, 2021,
available at: https://crsreports.congress.gov/product/pdf/IF/IF 11839.

[FN198]

. 'Money Follows the Person," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/long-term-services-supports/money-
follows-person/index.html.

[FN199]

. Fact Sheet, "People Dually Eligible for Medicare and Medicaid," CMS, Mar. 2020, available at: https:/Awww.cms.gov/Medicare-
Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf.

[FN200]

. State Medicaid Director Letter, "Three New Opportunities to Test Innovative Models of Integrated Care for Individuals Dually Eligible
for Medicaid and Medicare," SMD # 19-002, Apr. 24, 2019, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/
smd19002.pdf.

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[FN201]

. Fact Sheet, "People Dually Eligible for Medicare and Medicaid," CMS, Mar. 2020, available at: https:/Avww.cms.gov/
Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/
MMCO_Factsheet.pdf(footnotes omitted).

[FN202]

. Fact Sheet, "People Dually Eligible for Medicare and Medicaid," CMS, Mar. 2020, available at: https:/Awww.cms.gov/Medicare-
Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf.

[FN203]

. Financial Alignment Initiative for Medicare-Medicaid Enrollees,' CMS, available at: https://innovation.cms.gov/initiatives/Financial-
Alignment/.

[FN204]

. "Financial Alignment Initiative for Medicare-Medicaid Enrollees," Innovation Center web site, available at: https://innovation.cms.gov/
innovation-models/financial-alignment.

[FN205]

. State Medicaid Director Letter, SMD #18-012, "Ten Opportunities to Better Serve Individuals Dually Eligible for Medicaid and
Medicare," Dec. 19, 2018, available at: https://www.medicaid.gov/federal-policy-quidance/downloads/smd18012.pdf.

[FN206]

. State Medicaid Director Letter, "Three New Opportunities to Test Innovative Models of Integrated Care for Individuals Dually Eligible
for Medicaid and Medicare," SMD # 19-002, Apr. 24, 2019, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/
smd19002.pdf.

[FN207]

. State Medicaid Director Letter, "Three New Opportunities to Test Innovative Models of Integrated Care for Individuals Dually Eligible
for Medicaid and Medicare," SMD # 19-002, Apr. 24, 2019, available at: https:/Avwww.medicaid.gov/federal-policy-guidance/downloads/
smd19002.pdf (footnote omitted).

[FN208]

. State Medicaid Director Letter, "Ten Opportunities to Better Serve Individuals Dually Eligible for Medicaid and Medicare," SMD #
18-012, Dec. 19, 2018, available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/smd18012.pdf.

[FN209}

. See, Brian Castrucci and John Auerbach, "Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Health,"
the Health Affairs blog, January 16, 2019, available at: https:/Avww.healthaffairs.org/do/10.1377/hblog20190115.234942/full/; "Study
Calls for Clarity on SDOH, Related Terminology," American Academy of Family Physicians," June 10, 2019, available at: https://
www.aafp.org/news/practice-professional-issues/20190610sdohterms.html.

[FN210]

. Brian Castrucci and John Auerbach, "Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Health," the
Health Affairs blog, January 16, 2019, available at: https:/Avww.healthaffairs.org/do/10.1377/hblog20190115.234942/full/

[FN211]

. Samantha Artiga and Elizabeth Hinton, "Beyond Health Care: The Role of Social Determinants in Promoting Health and Health
Equity," Kaiser Family Foundation, May 10, 2018, available at: https:/Avww.kff.org/disparities-policy/issue-brief/beyond-health-care-the-
role-of-social-determinants-in-promoting-health-and-health-equity/.

[FN212]

. Stuart M. Butler, et a/., "Re-balancing Medical and Social Spending to Promote Health: Increasing State Flexibility to Improve
Health Through Housing," Brookings, Feb. 15, 2017, available at: https:/Avww.brookings.edu/blog/up-front/201 7/02/1 5/re-balancing-
medical-and-social-spending-to-promote-health-increasing-state-flexibility-to-improve-health-through-housing/; Deborah Bachrach,
et al., "Medicaid Coverage of Social Interventions: A Roadmap for States," Manatt on Medicaid, Aug. 10, 2016, available at: https://
www.manatt.com/Insights/Newsletters/Medicaid-Update/Medicaid-Coverage-of-Social-Interventions-A-Roadm.

[FN213]

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. Deborah Bachrach, e¢ al., "Enabling Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-
Setting Tools," Commonwealth Fund, January 2018, available at: http:/Awww.commonwealthfund.org/ /media/files/publications/fund-
report/2018/jan/bachrach_investment_social_interventions_medicaid_rate_setting.pdf.

[FN214]

. Samantha Artiga and Elizabeth Hinton, "Beyond Health Care: The Role of Social Determinants in Promoting Health and Health
Equity," Kaiser Family Foundation, May 10, 2018, available at: https:/Avww.kff.org/disparities-policy/issue-brief/beyond-health-care-
the-role-of-social-determinants-in-promoting-health-and-health-equity/?utm_campaign=KFF-2018-May-Social-Determinants-Of-
Health&utm_medium=email&_hsenc=p2ANqtz--W91kysVluDjGiUTSpJzjhzrqhYkXA3uHTB-3zVdlOtacMv2L8488bWbxOs066anH8F _
oEI7cZE8xhwDLe6Gomye0Tn9Q&_hsmi=62848037 &utm_content=628480378&utm_source=hs_ email&hsCtaTracking=b249209e-
fd67-4ac9-8f3c-d6a8d5c26cb5@99862a19-40b5-490d-b796-e8fc97b7c694.

[FN215]

. Damon Francis, "An Evolving Roadmap to Address Social Determinants of Health," Commonwealth Fund, Jan. 16,
2019, available at: https:/Avwww.commonwealthfund.org/blog/2019/evolving-roadmap-address-social-determinants-health?
omnicid=EALERT 1545961 &mid=.

[FN216]

. Elizabeth Hinton, et a/., "A First Look at North Carolina's Section 1115 Medicaid Waiver's Healthy Opportunities Pilots," Kaiser Family
Foundation, May 2019, available at: http://files.kff.org/attachment/Issue-Brief-A-First-Look-at-North-Carolinas-Section-1 115-Medicaid-
Waivers-Healthy-Opportunities-Pilots.

[FN217]

. Elizabeth Hinton, et al., "A First Look at North Carolina's Section 1115 Medicaid Waiver's Healthy Opportunities Pilots," Kaiser Family
Foundation, May 2019, available at: http:/Ailes.kff.org/attachment/Issue-Brief-A-First-Look-at-North-Carolinas-Section-1 115-Medicaid-
Waivers-Healthy-Opportunities-Pilots. (Emphasis in original; citation omitted.)

[FN218]

. Elizabeth Hinton, et al., "A First Look at North Carolina's Section 1115 Medicaid Waiver's Healthy Opportunities Pilots," Kaiser Family
Foundation, May 2019, available at: http://files.kff.org/attachment/Issue-Brief-A-First-Look-at-North-Carolinas-Section-1 115-Medicaid-
Waivers-Healthy-Opportunities-Pilots. (Citation omitted.)

[FN219]

. State Health Official Letter, "Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH)," #21-001, Jan. 7,
2021, available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/sho21001 pdf.

[FN220]

. State Health Official Letter, "Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH)," #21-001, Jan. 7,
2021, available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf.

[FN221]

. See, e.g., Press Release, "HHS Marks Black Maternal Health Week by Announcing Measures To Improve Maternal Health
Outcomes," CMS, Apr. 12, 2021, available at: https:/Awww.cms.gov/newsroom/press-releases/hhs-marks-black-maternal-health-
week-announcing-measures-improve-maternal-health-outcomes; Jennifer Haley and Emily M. Johnston, "Closing Gaps in
Maternal Health Coverage: Assessing the Potential of a Postpartum Medicaid/CHIP Extension," Jan. 29, 2021, available at: https://
www.commonwealthfund.org/publications/issue-briefs/2021/jan/closing-gaps-maternal-health-postpartum-medicaid-chip.

[FN222]

. For more detailed state-level information, please see "View Each State's Efforts to Extend Medicaid Coverage to Postpartum Women,"
National Academy for State Health Policy, updated Apr. 9, 2021, available at: https:/Avww.nashp.org/view-each-states-efforts-to-extend-
medicaid-coverage-to-postpartum-women/.

[FN223]

. MaryBeth Musumeci, "Medicaid Provisions in the American Rescue Plan Act," Kaiser Family Foundation, Mar. 19, 2021, available at:
https:/Avww.kff.org/medicaid/issue-brief/medicaid-provisions-in-the-american-rescue-plan-act/.

[FN224]

. Elisabeth Wright Burak and Maggie Clark, "Implementing American Rescue Plan's 12-month Postpartum Medicaid Coverage:
Federal and State Actions," Georgetown University Health Policy Institute, Say Ahhh Blog, Mar. 22, 2021, available at: https://

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ccf.georgetown.edu/2021/03/22/implementing-american-rescue-plans-12-month-postpartum-medicaid-coverage-federal-and-state-
actions/.
[FN225]

. Press Release, "HHS Marks Black Maternal Health Week by Announcing Measures To Improve Maternal Health Outcomes," HHS,
Apr. 12, 2021, available at: https:/Avww.cms.gov/newsroom/press-releases/hhs-marks-black-maternal-health-week-announcing-
measures-improve-maternal-health-outcomes.

[FN226]

. Press Release, "HHS Marks Black Maternal Health Week by Announcing Measures To Improve Maternal Health Outcomes," HHS,
Apr. 12, 2021, available at: https:/Avww.cms.gov/newsroom/press-releases/hhs-marks-black-maternal-health-week-announcing-
measures-improve-maternal-health-outcomes.

[FN227]
. 'Maternal Opioid Misuse (MOM) Model," CMS, available at: https://innovation.cms.gov/initiatives/maternal-opioid-misuse-model/.

[FN228]
. "Maternal Opioid Misuse (MOM) Model," CMS, available at: https://innovation.cms.gov/initiatives/maternal-opioid-misuse-model/.

[FN229]
. "Maternal Opioid Misuse (MOM) Model," CMS, available at: https://innovation.cms.gov/initiatives/maternal-opioid-misuse-model/.

[FN230]

. Press Release, "CMS Awards Funding to Combat Opioid Misuse among Expectant Mothers and Improve Care for Children Impacted
by the Crisis," CMS, Dec. 19, 2019, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-awards-funding-combat-opioid-
misuse-among-expectant-mothers-and-improve-care-children-impacted.

[FN231]

. CMCS Informational Bulletin, "Medicaid and CHIP Managed Care Monitoring and Oversight Tools," CMS, June 28, 2021, available at:
https:// web.archive.org/web/202 10628201649/https:/Avww. medicaid.gov/federal-policy-guidance/downloads/cib06282021.pdf.

[FN232]

. CMCS Informational Bulletin, "Medicaid and CHIP Managed Care Monitoring and Oversight Tools," CMS, June 28, 2021, available at:
https:// web.archive.org/web/20210628201649/https:/Awww.medicaid.gov/federal-policy-guidance/downloads/cib06282021.pdf.

[FN233]

. "Medicaid and CHIP Managed Care Final Rules," Medicaid.gov, available at: https:/Awww.medicaid.gov/medicaid/managed-care/
guidance/medicaid-and-chip-managed-care-final-rules/index.html.

[FN234]

. Press Release, 'Portman Joined Bipartisan Group of Senators to Urge CMS to Expand Substance Abuse Treatment Coverage,' web
site of Senator Rob Portman (R), Aug. 2, 2016, available at: http:/Avww.portman.senate.gov/public/index.cfm/2016/8/portman-joined-
bipartisan-group-of-senators-to-urge-cms-to-expand-substance-abuse-treatment-coverage.

[FN235]

. See, e.g., Alison Knopf, 'Medicaid Rule puts IMD Exclusion in Better Context,' Behavioral Health Care, June 7, 2016, available at:
http://www. behavioral.net/article/medicaid-rule-puts-imd-exclusion-better-context.

[FN236]

. Press Release, "CMS Proposes Changes to Streamline and Strengthen Medicaid and CHIP Managed Care Regulations," Nov. 8,
2018, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-proposes-changes-streamline-and-strengthen-medicaid-and-
chip-managed-care-regulations.

[FN237]

. Press Release, "CMS Proposes Changes to Streamline and Strengthen Medicaid and CHIP Managed Care Regulations," Nov. 8,
2018, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-proposes-changes-streamline-and-strengthen-medicaid-and-
chip-managed-care-regulations.

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[FN238]

. The IMD exclusion prohibits Medicaid payments for inpatient mental health treatment in "Institutes for Mental Diseases" with more
than 16 beds.

[FN239]

. Press Release, "CMS Proposes Changes to Streamline and Strengthen Medicaid and CHIP Managed Care Regulations," Nov. 8,
2018, available at: https:/Awww.cms.gov/newsroom/press-releases/cms-proposes-changes-streamline-and-strengthen-medicaid-and-
chip-managed-care-regulations.

[FN240]

. "Fact Sheet: Notice of Proposed Rulemaking (NPRM); Medicaid Program; Medicaid and Children's Health Insurance Program (CHIP)
Managed Care (CMS-2408-P)," CMS, Nov. 8, 2018, available at: https:/Avww.medicaid.gov/medicaid/managed-care/downloads/
guidance/factsheet-cms-2408-p.pdf.

[FN241]

. Elizabeth Hinton and MaryBeth Musumeci, "CMS's 2020 Final Medicaid Managed Care Rule: A Summary of Major Changes," Kaiser
Family Foundation, Nov. 23, 2020, available at:https://www.kff.org/report-section/cmss-2020-final-medicaid-managed-care-rule-issue-
brief/.

[FN242]

. CMCS Informational Bulletin, "Medicaid Managed Care Frequently Asked Questions (FAQs) ? Medical Loss Ratio," June 5, 2020,
available at: https:/Awww.medicaid.gov/sites/default/files/F ederal-Policy-Guidance/Downloads/cib060520_new.pdf.

[FN243]

. Stephanie Oum, et a/., "The U.S. Response to Coronavirus: Summary of the Coronavirus Preparedness and Response Supplemental
Appropriations Act, 2020," Kaiser Family Foundation, Mar. 11, 2020, available at: https:/Avww.kff.org/global-health-policy/issue-brief/
the-u-s-response-to-coronavirus-summary-of-the-coronavirus-preparedness-and-response-supplemental-appropriations-act-2020/.

[FN244]

. Kellie Moss, et al., "The Families First Coronavirus Response Act: Summary of Key Provisions," Kaiser Family Foundation, Mar. 23,
2020, available at: https:/Avww.kff.org/coronavirus-covid-19/issue-brief/the-families-first-coronavirus-response-act-summary-of-key-
provisions/.

[FN245]

. "Families First Coronavirus Response Act ? Increased FMAP FAQs," available at: https:/Avww.medicaid.gov/state-resource-center/
downloads/covid-19-section-6008-faqs.pdf.

[FN246]

. 'Families First Coronavirus Response Act ? Increased FMAP FAQs," available at: https:/Avwww.medicaid.gov/state-resource-center/
downloads/covid-19-section-6008-faqs. pdf.

[FN247]

. "Operationalizing Implementation of the Optional COVID-19 Testing (XXIII) Group Potential State Flexibilities," CMS, available at:
https:/Avww.medicaid.gov/state-resource-center/downloads/potential-state-flexibilities-guidance.pdf.

[FN248]

. "Families First Coronavirus Response Act (FFCRA), Public Law No. 116-127 Coronavirus Aid, Relief, and Economic Security
(CARES) Act, Public Law No. 116-136 Frequently Asked Questions (FAQs), Medicaid.gov, Apr. 13, 2020, available at: https://
www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-CARES-faqs. pdf.

[FN249]

. The Money Follows the Person program seeks to increase the use of home- and community-based services over institutional care.
See "Money Follows the Person," Medicaid.gov, available at: https:/Avww.medicaid.gov/medicaid/long-term-services-supports/money-
follows-person/index.html.

[FN250]

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. Kellie Moss, et al., "The Coronavirus Aid, Relief, and Economic Security Act: Summary of Key Health Provisions," Kaiser Family
Foundation, Apr. 9, 2020, available at: https:/Avww.kff.org/global-health-policy/issue-brief/the-coronavirus-aid-relief-and-economic-
security-act-summary-of-key-health-provisions/. The act is available on Westlaw at 2019 Cong US HR 748 (2019 FD H.B. 748 (NS)).

[FN251]
. P.L. 116-139.

[FN252]

. Kellie Moss, "The Paycheck Protection Program and Health Care Enhancement Act: Summary of Key Health Provisions," Kaiser
Family Foundation, May 1, 2020, available at: https:/Avww.kff.org/global-health-policy/issue-brief/the-paycheck-protection-program-and-
health-care-enhancement-act-summary-of-key-health-provisions/?utm.

[FN253]
. PLL. 117-2.

[FN254]
. FMAP is the federal medical assistance percentage, or matching rate that a state receives from the federal government.

[FN255]

. MaryBeth Musumeci, "Medicaid Provisions in the American Rescue Plan Act," Kaiser Family Foundation, Mar. 18, 2021, available at:
https:/Avww.kff.org/medicaid/issue-brief/medicaid-provisions-in-the-american-rescue-plan-act/.

[FN256]

. CMCS Informational Bulletin, "Medicaid, Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) Related
Provisions in the American Rescue Plan Act of 2021," CMS, June 3, 2021, available at: https:/Avww.medicaid.gov/federal-policy-
guidance/downloads/cib060321.pdf.

[FN257]

. Fact Sheet, "Establishing Minimum Standards in Medicaid State Drug Utilization Review (DUR) and Supporting Value-Based
Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements (CMS
2482-F) Final Reg," CMS, Dec. 21, 2020, available at: https:/Awww.cms.gov/newsroom/fact-sheets/establishing-minimum-standards-
medicaid-state-drug-utilization-review-dur-and-supporting-value-based-0.

[FN258]

. Fact Sheet, "Establishing Minimum Standards in Medicaid State Drug Utilization Review (DUR) and Supporting Value-Based
Purchasing (VBP) for Drugs Covered in Medicaid, Revising Medicaid Drug Rebate and Third Party Liability (TPL) Requirements (CMS
2482-F) Final Reg," CMS, Dec. 21, 2020, available at: https:/Awww.cms.gov/newsroom/fact-sheets/establishing-minimum-standards-
medicaid-state-drug-utilization-review-dur-and-supporting-value-based-0.

[FN259]
. The final rule is published at 86 F.R. 64819-01 (Nov. 19, 2021).

[FN260]
. FMAP is the federal medical assistance percentage, or matching rate that a state receives from the federal government.

[FN261]

. Press Release, "Casey, Booker and Colleagues Urge Administration to Push Forward with Investments in Home and Community-
Based Services," Senate Committee on Aging, Feb. 5, 2021, available at: https:/Avww.aging.senate.gov/press-releases/casey-booker-
and-colleagues-urge-administration-to-push-forward-with-investments-in-home-and-community-based-services.

[FN262]

. Letter to Pres. Joseph Biden signed by Sen. Bob Casey and 30 other senators, Feb. 5, 2021, available at: https://
www.aging.senate.gov/imo/media/doc/Casey-Booker#CBSL#etter#oP#resB#iden.pdf.

[FN263]

. Press Release, "Bennet, Colleagues Introduce Bicameral Legislation to Expand Medicaid Coverage for COVID-19 Treatment,
Vaccines," web site of Sen. Bennet, Feb. 8, 2021, available at: https:/Avwww.bennet.senate.gov/public/index.cfm/2021/2/bennet-
colleagues-introduce-bicameral-legislation-to-expand-medicaid-coverage-for-covid-1 9-treatment-vaccines.

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[FN264]

. "US S 274 Stronger Medicaid Response to the COVID?19 Pandemic Act," bill summary by Bill Track 50, available at: https://
www.billtrack50.com/BillDetail/1306308.

[FN265]

. Akeeisa Coleman, "How Will the American Rescue Plan's Medicaid Funding Help States?" The Commonwealth Fund Blog, Mar. 29,
2021, available at: https:/Awww.commonwealthfund.org/blog/202 1/how-will-american-rescue-plans-medicaid-funding-help-states.

[FN266]
. The FMAP is the Federal Medical Assistance Percentage, or match rate, from the federal government.

[FN267]

. Press Release, "Bennet, Colleagues, Introduce Bill to Support State Medicaid Programs During an Economic Crisis," web site of
Sen. Bennet, Feb. 26, 2021, available at: https:/Awww.bennet.senate.gov/public/index.cfm/2021/2/bennet-colleagues-introduce-bill-to-
support-state-medicaid-programs-during-an-economic-crisis.

[FN268]

. FMAP is the Federal Medical Assistance Percentage, or the match rate.

[FN269]

. Press Release, "Rubio Reintroduces Bill to Modernize Medicaid DSH, Help Hospitals Providing Care to Low-Income
Patients," Sen. Rubio's web site, June 11, 2021, available at: https:/Awww.rubio.senate.gov/public/index.cfm/press-releases?
ID=97766731-179C-44AC-8ED4-07075F88DCC7.

[FN270]

. Press Release, "Kuster, Fitzpatrick, Booker Introduce Bipartisan Legislation to End Outdated Policy that Prevents Incarcerated
Individuals from Accessing Medicaid," Rep. Kuster's web page, May 25, 2021, available at: https://kuster.house.gov/news/
documentsingle.aspx? DocumentID=3626.

[FN271]

. For more information on federal Medicaid funding for the territories, please see Fact Sheet, "Medicaid and CHIP in the
Territories," MACPAC, Feb. 2021, available at: https:/Avwww.macpac.gov/wp-content/uploads/201 9/07/Medicaid-and-
CHIP-in-the-Territories.pdf; "Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier," Kaiser Family
Foundation, Fiscal Year 2022, available at: https://Awww.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN272]

. Press Release, "Plaskett Introduces Legislation to Improve Medicaid and Medicare in U.S. Territories," web site of Rep. Plaskett, May
15, 2021, available at: https://plaskett.house.gov/news/documentsingle.aspx?DocumentID=188.

[FN273]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated July 9, 2021, available at:
https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN274]

. "Casey, Colleagues Unveil Key Legislation from President Biden's American Jobs Plan to Make Historic Investment in Care
Economy," Sen. Casey's web site, June 24, 2021, available at: https:/Awww.casey.senate.gov/news/releases/casey-colleagues-unveil-
key-legislation-from-president-bidens-american-jobs-plan-to-make-historic-investment-in-care-economy.

[FN275]
. 'Inadmissibility on Public Charge Grounds," Dept. of Homeland Security, published at 84 F.R. 41292 (Aug. 14, 2021).

[FN276]
- Notice, "Field Guidance on Deportability and Inadmissibility on Public Charge Grounds," 64 F.R. 28689 (Mar. 26, 1999).

[FN277]

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. Informational Bulletin, "Public Charge and Safeguarding Beneficiary Information," July 22, 2021, available at: https://
www.medicaid.gov/federal-policy-guidance/downloads/cib072221.pdf.

[FN278]

. Press Release, "Senators Baldwin, Reverend Warnock, Ossoff Introduce New Legislation to Expand Quality, Affordable Health Care
Coverage," web site of Sen. Tammy Baldwin, July 12, 2021, available at: https:/Awww.baldwin.senate.gov/press-releases/medicaid-
saves-lives-act.

[FN279]

. Press Release, "Senators Baldwin, Reverend Wamock, Ossoff Introduce New Legislation to Expand Quality, Affordable Health Care
Coverage," web site of Sen. Tammy Baldwin, July 12, 2021, available at: https:/Awww.baldwin.senate.gov/press-releases/medicaid-
saves-lives-act.

[FN280]

. Sara Rosenbaum, et al., "How the Medicaid Saves Lives Act and Other Federal Options Can Ensure All Americans Have Access to
Affordable Coverage," The Commonwealth Fund Blog, Aug. 5, 2021, available at: https:/Avwww.commonwealthfund.org/blog/2021/how-
medicaid-saves-lives-act-and-other-federal-options-can-ensure-all-americans-have?. The American Rescue Plan is P.L. 117-2. FMAP
is a state's federal medical assistance percentage.

[FN281]

. The proposed rule is published at 86 F.R. 41803 (Aug. 3, 2021).

[FN282]
. Email update from Medicaid.gov, "CMS Proposes Rule to Support Home Care Workers Access to Benefits," July 30, 2021.

[FN283]

. State Health Official Letter, "Planning for the Resumption of Normal State Medicaid, Children's Health Insurance Program (CHIP),
and Basic Health Program (BHP) Operations upon Conclusion of the COVID-19 Public Health Emergency," #20-004, Dec. 22, 2020,
available at: https:/Awww.medicaid.gov/federal-policy-guidance/downloads/sho20004. pdf.

[FN284]

. State Health Official Letter, ": Updated Guidance Related to Planning for the Resumption of Normal State Medicaid, Children's Health
Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency,"
CMS, Aug. 13, 2021, SHO #21-002, available at: https:/Avww.medicaid.gov/federal-policy-guidance/downloads/sho-21-002.pdf.

[FN285]

. CMCS Informational Bulletin, "Third Party Liability in Medicaid: State Compliance with Changes Required in Bipartisan Budget Act of
2018 and Medicaid Services Investment and Accountability Act of 2019, CMS, Aug. 27, 2021, available at: https:/Awww.medicaid.gov/
federal-policy-guidance/downloads/cib082721 .pdf.

[FN286]

. "State Health Official Letter, "Medicaid and CHIP Coverage and Reimbursement of COVID-19 Testing under the American
Rescue Plan Act of 2021 and Medicaid Coverage of Habilitation Services," SHO #21-003, CMS, Aug. 30, 2021, available at: https://
www.medicaid.gov/federal-policy-quidance/downloads/sho-21-003.pdf.

[FN287]

. "State Health Officer Letter, "Temporary Increases to FMAP under Sections 9811, 9814, 9815, and 9821 of the ARP and
Administrative Claiming for Vaccine Incentives," SHO #21-004, CMS, Aug. 30, 2021, available at: https://www.medicaid.gov/federal-
policy-guidance/downloads/sho-21-004.pdf.

[FN288]

. 'Available Flexibilities and Funding Opportunities to Address COVID-19 Vaccine Hesitancy," CMS, https:/Avww.medicaid.gov/state-
resource-center/downloads/avail-flex-fund-oppo-addr-covid-1 9-vac-hesit.pdf.

[FN289]

. State Health Official Letter, #21-005, "Medicaid Eligibility for COFA Migrants," CMS, Oct. 18, 2021, available at: https://
www.medicaid.gov/federal-policy-guidance/downloads/sho21005. pdf.

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[FN290]

. State Health Official Letter, #21-005, "Medicaid Eligibility for COFA Migrants," CMS, Oct. 18, 2021, available at: https://
www.medicaid.gov/federal-policy-guidance/downloads/sho21005.pdf.

[FN291]

. "Status of State Medicaid Expansion Decisions: Interactive Map," Kaiser Family Foundation, updated Feb. 1, 2020, available at:
https:/Avww.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[FN292]
. PACE stands for Programs of All-Inclusive Care for the Elderly.

[FN293]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 7, 2021, available
at: https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN294]

. For more information about Medicaid coverage for individuals covered by the Compact of Freely Associated States, please see "FAQ:
What Does COFA Medicaid Restoration Mean?" Asian and Pacific Islander American Health Forum, https://www.apiahf.org/resource/
faq-what-does-cofa-medicaid-restoration-mean/.

[FN295]

. For more information about these partnership plans, see "State Long Term Care Partnerships | Policies & Programs," LTC Partner,
available at: https:/Awww.longtermcareinsurancepartner.com/long-term-care-insurance/state-long-term-care-partnerships-policies-
programs.

[FN296]

. Michael David Raso, "Louisiana Budget Project Says Bill 186 Will Strip Child Support Payments From Children in Need; Rep. Bacala
Says Otherwise," Big Easy Magazine, Apr. 1, 2021, available at: https:/Avww. bigeasymagazine.com/2021/04/01/louisiana-budget-
project-says-bill- 186-will-strip-welfare-payments-from-children-in-need-rep-bacala-says-otherwise1/.

[FN297]

. Michael David Raso, "Louisiana Budget Project Says Bill 186 Will Strip Child Support Payments From Children in Need; Rep. Bacala
Says Otherwise," Big Easy Magazine, Apr. 1, 2021, available at: https:/Avww.bigeasymagazine.com/2021/04/01/louisiana-budget-
project-says-bill-186-will-strip-welfare-payments-from-children-in-need-rep-bacala-says-otherwise1/.

[FN298]

. 'Veto of House Bill 698 of 2021 Session," July 1, 2021, Letter from Gov. Bel Edwards to the Speaker of the House of Representatives,
July 1, 2021, available at: https://gov.louisiana.gov/assets/docs/2021session/vetoes/SchexnayderLtr20210701VetoHB698.pdf.

[FN299]

. Press Release, "CMS Announces New Medicaid Demonstration Opportunity to Expand Mental Health Treatment Services," CMS,
Nov. 13, 2018, available at: https:/Avww.cms.gov/newsroom/press-releases/cms-announces-new-medicaid-demonstration-opportunity-
expand-mental-health-treatment-services.

[FN300]

. "Status of State Action on Medicaid Expansion Decision," Kaiser Family Foundation, Nov. 2, 2020, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN301]

. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 7, 2021, available
at: https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN302]

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. "Status of State Action on the Medicaid Expansion Decision," Kaiser Family Foundation, updated June 7, 2021, available
at: https:/Avww.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN303]

- "Vermont All-Payer ACO Model," CMS, available at: https://innovation.cms.gov/innovation-models/vermont-all-payer-aco-model.

[FN304]

. For more information about the Fast-Track process, please see VA ST ? 2.2-4012.1.

[FN305]

. "Status of State Action on the Medicaid Expansion Decision," updated July 9, 2021, available at: https://
www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?
currentTimeframe=0&sortModel=#c#olld:#L#ocation,#s#ort:#asc'#.

[FN306]

. For more information on the Roads To Community Living demonstration, please see "Roads to Community Living, Washington
Department of Social and Health Services, available at: https:/Awww.dshs.wa.gov/dda/consumers-and-families/roads-community-living.

[FN307]

. "Status of State Medicaid Expansion Decisions: Interactive Map," Kaiser Family Foundation, Nov. 19, 2021, available at: https://
www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[FN308]
. P.L. 116-127.

[FN309]

. MaryBeth Musumeci, "Key Questions about the New Increase in Federal Medicaid Matching Funds for COVID-19," Kaiser Family
Foundation, May 4, 2020, available at: https://www.kff.org/medicaid/issue-brief/key-questions-about-the-new-increase-in-federal-
medicaid-matching-funds-for-covid-19/?utm_campaign=KFF-2020-Medicaid&utm.

[FN310]

. MaryBeth Musumeci, "Key Questions About the New Medicaid Eligibility Pathway for Uninsured Coronavirus Testing," Kaiser Family
Foundation, May 4, 2020, available at: https://www.kff.org/medicaid/issue-brief/key-questions-about-the-new-medicaid-eligibility-
pathway-for-uninsured-coronavirus-testing/?utm_campaign=KFF-2020-Medicaid&utm.

[FN311]

. Elizabeth Hinton, et a/., "What Does CMS Approval of First COVID-19 Section 1115 Waiver in Washington Mean for Other States?"
Kaiser Family Foundation, May 1, 2020, available at: https:/Awww.kff.org/medicaid/issue-brief/what-does-cms-approval-of-first-covid-19-
section-1115-waiver-in-washington-mean-for-other-states/?utm_campaign=KFF-2019-The-Latest&utm.

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