Medicaid Watch: State Medicaid and Health Cuts & Expansions 1-2007

Medicaid Watch: State Medicaid and Health Cuts & Expansions

By Thomas P. McCormack draft # 38, January 1, 2007

Alabama--- Has no spend down; allows only 12 doctor visits & hospital days yearly and 4 brand name Rx’s monthly (plus unlimited generics); but new SCHIP applications are again allowed. There’s a very long ADAP waiting list. The state plans to raise doctor payments. Alabama Blue Cross now offers a discount plan ($167/mo/indiv; $368/mo/fam) to the uninsured not on Medicare, but with a 12/mo preexisting condition wait plus big deductibles ($1,000; $250 for Rx’s) & co-pays.

Alaska---this Title XVI state, with no spend down, froze its nursing home income level; cut the CHIP level from 200% FPL to 175% (1,200 families lost children’s coverage); tightened qualifications for home care; and created a SPAP (with only token benefits) for the aged but not the disabled. There’s an ADAP waiting list.

Arizona---has no spend down; a waiver gives AHCCES (SCHIP & Medicaid) to all        uninsured parents & children under 200% & to all (even non-disabled) childless adults under 100%. CMS agreed, before the DRA’s passage, to let the state the state set higher co-pays (e.g., $10 per brand name Rx, $5 per generic, $5 per doctor visit), but a court has-      -at least so far--blocked them. The state did raise parental premiums on a sliding scale.

Arkansas--- Outgoing Gov. Huckabee’s (R) $100 million in higher tobacco & income taxes saved the spend down, Katie Beckett waivers & adult vision care & preserved nursing home rates. Yet fees are still too low to attract enough doctors; there’s an ADAP waiting list; and a state board is studying ways to cut the Medicaid budget. A HIFA Medicaid waiver funds barebones health insurance for 50,000 workers & spouses with incomes under 200% ($15/mo premium; 7 doctor visits & hospital days a year & 2 Rx’s monthly; $100 deductible; 15% coinsurance); the plan is also open to 30,000 “richer” families for $100 monthly. The state raised children’s dental fees to 95% of the private Delta Dental rates; seeks to fund most adult dental care (versus just emergency extractions, like most states); and says its new formulary saves $20 million yearly.

California---red tape & a lower income level have taken 200,000 parents off the rolls since 2004. Gov. Schwarzenegger (R) called for premiums ($4 to $27) for those over 100% or the SSI level, is forcing the aged & disabled into HMOs, proposed a yearly patient dental care cap of $1,000, agreed with CMS & the legislature on only $3.3 billion more in DSH federal funds for 5 years; made 5% doctor rate cuts; and stopped paying extra Medicare HMO premiums for dual eligibles---but supported raising SSP levels to $849 monthly ($1491/couple); spending $50 million more to expand CHIP; starting 500 health clinics in low income schools; banning patient balance billing for ER visits; and making drug makers give discounts to the moderate income uninsured. Yet he vetoed the Democratic legislature’s universal coverage bill & his health reform board called for ending mandated HMO coverage of contraception, mental health care & cancer screening.

Colorado---has no spend down; a court voided a law to deny benefits to legal aliens & once-blocked CHIP applications are again accepted. An added $2 million in state funds eased the ADAP waiting list. Cigarette taxes voted by referendum will raise the CHIP level from 185% to 200% (covering 4,000 more children), open 600 more HCB and/or Katie Beckett waiver slots to disabled children, raise funding for low income clinics & raise the parents’ income level to 60% (covering 90,000 more). HIFA waiver plans were dropped, but the state will save $59 million by shifting children into HMOs. The legislature, opposed by both drug makers & some consumer groups (but for quite different reasons), plans to adopt a drug formulary to save even more than does the current prior authorization system for some drugs & services. Denver’s Medical Center & the Univ. of Col. Hospital cut their in-house indigent care programs & raised their co-pays and the Colorado Indigent Care plan for those not eligible for Medicaid, such as the childless poor awaiting SSA disability decisions, raised its co-pays too: $10 per Rx, $35 per doctor visit, $270 per hospital stay & $15 to $45 per ER visit. The legislature cut rates 15% to the ColoradoAccess HMO, which then dumped its 65,000 patients into fee-for-service Medicaid; but it raised funding for the risk pool (allowing premium discounts of 50% if income is below $$40,000, and 40% if under $50,000); set up a board to study health coverage expansion; and required the Medicaid agency to adopt a consumer-run board’s care plans for the disabled by 1/07 or no later than 6 months after any required waiver approval.

Connecticut—a 209(b) state; Governor Rell (R ) added doctor co-pays of $1 to $3; upped SPAP premiums to $30 & its co-pays to $16.25; imposed a $100,000 SPAP asset test; required recoveries of SPAP costs from the deceased’s estates; dropped legal aliens from TANF, Medicaid, CHIP & SAGA (state-funded welfare & medical programs); forced SAGA patients into HMOs; set up a board to study Medicaid “reforms”; ended Medicaid coverage of adult chiropractor, naturopath, psychologist and occupational. physical & speech therapy services; and introduced—but then dropped as uncollectible-- $1 Medicaid Rx co-pays. But the Democratic legislature raised the parents’ level back up to 150% and repealed Rell’s earlier family & CHIP premium hikes. Medicaid & CHIP specialist & dentist rates are too low to attract enough providers-- so in 2007 the state will, at least temporarily, raise most pediatric dental fees to 70% of private insurers’ rates. The state offers Medicaid to the working disabled and even the working “recovered/ex-disabled”. Rell proposed barebones insurance with $250 monthly premiums & $1,000 deductibles for the uninsured between 18 and 64—but failed to offer or budget state subsidies for the plan, resulting so far in little insurance industry interest or response.

Delaware---has no spend down, but a waiver covers all adults (even if not parents or disabled) under 100%, yet it caps yearly SPAP benefits. Gov. Minner (D) created a Cancer Treatment Program for the uninsured not on Medicare under 650% (!) and a state indigent health program for those under 200%; added $5 million for caseload growth; raised provider rates to 65% of private insurance levels; and proposed funding Medicaid buy-in coverage for the working disabled.

District of Columbia---the locally-funded Health Alliance covers all the uninsured under 200% except Medicare & Medicaid eligibles. DC’s Medicaid levels are 100% for the childless aged & disabled and 200% for parents & children. A $240 million “DC Homes” plan will strengthen preventive health, cancer screening, anti-smoking, ER & ambulance services; and upgrade, expand & add more primary clinics. DC also raised its home health & personal care aides’ pay; added coverage of adult dental care; raised all its dental rates; and will subsidize indigent dental care at Howard U. Dental School & low income clinics. DC raised its QMB & SLMB income levels up to $1809 monthly --not only making many more Medicare patients eligible for payment of Medicare premiums & cost-sharing, but thereby also for Part D’s full Extra Help. Yet DC’s 2007 Medicaid & related budget is now short $87 million---mostly due to undeveloped eligibility workups (and thus unclaimed matching) for DC wards with CMI, MR & DD-- that will rise to $300 million thru 2008; and a DC audit said it could have saved $38 million by better promoting HCB waivers instead of nursing home care.

Florida---outgoing Gov. Bush (R ) began to outsource Medicaid, welfare & food stamp eligibility to contractors; and his waiver to privatize Medicaid & convert it, with premium support & health savings accounts, into a “defined contribution” HMO-type insurance was approved by CMS (see Understanding Florida’s Medicaid Waiver Application at www.wphf.org & http://theaidsinstitute.org/downloads/FloridaMedicaidreform.pdf ); a waiver pilot started in 2 counties in September. Even sooner, 43,000 patients over 60 in northern & central counties are being enrolled in a 2nd waiver that favors home-based care over nursing homes. The state cut the aged/disabled Medicaid income eligibility level from $719 to $603 on 1/1/06 (77,000 lost coverage); set up a Medicaid “reform” board and abolished its SPAP 1/1/06. A “fail first” rule allows costly mental health drugs only if cheaper ones don’t work (with Lamictal, Paxil, Wellbutrin, Lexapro, Zoloft & Zyprexa exempted). The state again covers adult dentures & hearing aids and takes SCHIP applications year-round. Children’s, health , doctor & dentist groups sued to raise children’s care fees and made the state drop a prior approval rule for nutrition supplements; and pediatricians objected to slow Medicaid prior approvals for flu vaccine dose prescriptions. Dade County launched a $40 million plan for school nurses’ routine care & to enroll students in Medicaid & SCHIP.

Georgia---ended CHIP coverage of oral surgery & other dental work and cut the Medicaid & WIC level for pregnant women (7,500 lost coverage) & infants from 235% to 200%; raised CHIP premiums to range from $10 to $35 monthly per child; ended adult coverage of emergency dental care & artificial limbs; is moving 1 million patients (including 100,000 aged & disabled and 200,000 on CHIP) into HMOs that doctors & clinics say have obstructive prior authorization rules & lack specialists (while red tape snafus also left some without proper transfer forms to go without any coverage at all); ended spend down eligibility for nursing home care (but attorneys using complex trusts can still get eligibility for some); dropped adult dental care, orthotics, prosthetics & hospice care; set up still another health insurance & Medicaid “reform” board; capped HCB care costs; and tightened medical eligibility for Katie Beckett waiver care (which a 2006 supplemental budget shifts into a public-private body that proponents say bolsters funding). Gov. Perdue (R ) is renewing his only briefly postponed Medicaid “reform” plan to further cut nursing home access, raise co-pays (even for children & nursing home patients) and add more managed care & health savings account features to Medicaid. A state health board voted to eliminate the 90 day coverage suspensions for children with parents delinquent in paying CHIP premiums, but the state’s ADAP may have to take some cost-containment steps. CMS forbade further use of the accounting gimmicks that have brought in $300 million yearly in federal funds & questioned $70 million in foster children’s mental health costs. The rolls dropped by 60,000 in 2006 due to stricter eligibility re-determination & document verification procedures.

Guam—this territory’s Medicaid matching rate is capped by law far below what a state would get. The local medically indigent plan pays less than Medicaid & attracts fewer providers. Private managed care firms want contracts which they say can save enough to pay providers more. Funds for off-island specialty care, and air transportation to it, are exhausted.

Hawaii—a 209(b) state; a “Quest” waiver gives Medicaid to parents & uninsured, childless adults not on Medicare under 200%, except for the childless aged & disabled, who must be under 100% to get it. The state requires employers to offer health coverage to employees & dependents and created a token SPAP for aged and disabled patients, with a mere 100% income level. Gov. Lingle (R) raised the child & parent level to 250% (covering 29,000 more); lowered CHIP premiums; restored some adult dental care through both Medicaid & dental charity programs and expanded substance abuse care.

Idaho---this Title XVI state, with no spend down, raised the CHIP level from 150% to 185% (but with less benefits & more co-pays than for poorer patients); funded a pilot barebones health plan for 1,000 adults; and covered the working disabled. But it cut funds for non-federal medical aid for the temporarily disabled & those awaiting SSA disability decisions; ended mandates for private health insurance coverage of breast & prostate cancer screening & mental health; and got CMS approval to set up 3 patient classes: Parents & children (with a $13 million lower yearly care budget & more cost-sharing and/or coverage cuts) ; the disabled & chronically ill; and the aged. The first (but later the others too) will face more cost-sharing & there’ll be different (perhaps lesser) benefits for each class, but with more preventive care & incentives. See http://healthandwelfare.idaho.gov/site/3629/default.aspx for a description. There’s an ADAP waiting list.

Illinois---this 209(b) state’s main SPAP (funded as a Medicaid Pharmacy Plus waiver) excludes the disabled, who get only a limited formulary from a 2^nd, separate Circuit Breaker SPAP. Gov. Blagjoievich (D) added HIV drugs to the 2^nd formulary (but only for those on Medicare); raised the family income level to 185%; and signed a hospital tax to fund healthcare. Then he authorized “universal” SCHIP coverage, with more cost-sharing for “richer” families; accepted a court order raising children’s doctor, specialist & EPSDT rates; and offered subsidized health insurance to uninsured veterans left uncovered by Administration VA cuts. The state is considering adopting a PCCM primary physician plan, letting anyone under 300% buy-in to Medicaid & raising its provider rates. A legislative health reform task force proposed a Mass.-like expansion plan: Medicaid for parents & children under 200% (but only 100% for childless adults, including aged & disabled); a health insurance mandate for all residents & employers; sliding scale premium subsidies; tax & other incentives for small firms--to cost the state $3.5 billion & employers $1.5 billion. HMO enrollment is still voluntary.

Indiana---this 209(b) state’s SPAP still excludes the disabled; and, despite court suits, it still has a much-stricter-than-SSI “209(b)” Medicaid disability rule (one must be fatally or incurably ill). Gov. Daniels (R ) and the GOP legislature will double CHIP premiums & cut the HCB waiver budget by $14 million yet will let Medicare patients into the risk pool for secondary coverage at discounted rates & add 500 more HCB waiver slots (although a KPMG audit found many waiver problems). There’s now an ADAP waiting list; and the ACLU filed suit challenging an only-once-every-6-years limit on dentures & relinings. Plans to spend $1 billion on privatizing food stamp, welfare & Medicaid eligibility that will shrink 107 welfare offices by up to 2,500 workers face growing public opposition, possibly critical hearings by the incoming Democratic state House and more delay in getting federal approval. The state tightened its lax spend down procedures (too much & too soon, it turned out, after a class action suit forced it to accept a consent order reinstating 12,606 aged & disabled dropped without even hearing rights); funded service plans for 650 more disabled clients; and is enrolling patients in managed care plans that, doctors say, will pay even less than regular Medicaid now does --further cutting provider participation & access to primary & specialist care and thus generating more costly ER visits (the state then said it will raise doctor fees). Daniels, supported by HHS, plans an expansion (probably with a HIFA waiver) to subsidize barebones coverage for parents under 200% & all--even non-disabled--childless adults (under 100%), using HMOs, health savings accounts & preventive care measures; see http://www.in.gov/serv/presscal?PF=gov2&Clist=196&Elist=87673.

Iowa---the state has a waiver to give watered-down Medicaid (with premiums up to 5% of income) to up to 30,000 uninsured adults not on Medicare--whether they’re aged, disabled, a parent or not--with incomes under 200% but only at 2 public hospitals---but with no uniform statewide waiver drug benefit: Those who are also prior U. of IA hospital “state papers” indigent program patients are nominally grandfathered-in, only for a year & with high co-pays, for its free drug formulary; while Des Moines-area waiver patients can also access a Polk County public hospital’s indigent drug formulary; but drug coverage for other waiver eligibles is sketchy or non-existent. The ADAP waiting list, at least for now, has been alleviated by now-expired extra emergency federal funding and some added state funds. A legislative committee began to study ways to cut Medicaid, but incoming Gov. Culver (D) supports a $1-a-pack cigarette tax hike to expand insurance subsidies for more families; while Democratic legislators propose covering 20,000 more children & 9,000 parents in SCHIP, raising Medicaid income levels and expanding health insurance subsidies for the working poor.

Kansas---this Title XVI state’s SPAP was abolished 1/1/06. Spurning Gov. Sibelius’ (D) call for more health coverage, the GOP legislature passed a limited tax credit to expand small firm coverage, health savings account measures, a health care re-organization & called for more anti-fraud efforts—but did raise provider fees from 65% to 83% of Medicare’s rate. Blue Cross & a foundation subsidize barebones insurance for Kansas City-area families making under $30,000. The state may have to impose ADAP cost containments; is considering higher co-pays for smokers & the obese and stricter motorcycle helmet laws & other preventive health steps; and offers Medicaid to the working disabled, the working “pre-disabled” (only if they’re in the state risk pool & have severe impairments) and the working “medically improved”/ex- disabled”. Because the state plan limited coverage of disabled institutionalized children to 140/180 days—even though longer stays are allowed by federal law—CMS questioned matching for over 500 of them, making the state send them to regular foster care, small group homes or state hospitals. A federal audit disallowed $5 million & questioned $127 million more in old Medicaid matching claims for special needs students; and the state had to refund $14 million in another audit.

Kentucky--- the state raised Rx co-pays to $1 per generic, $2 per preferred brand name & $3 per non-preferred brand name drug. But it dropped earlier-tightened nursing home & HCB care medical qualification rules; raised the cigarette tax by 30 cents-a-pack (to fund education & Medicaid) with a further 10-cent raise under study; reinstated 2,500 formerly-dropped mentally ill clients; and enrolled all those once on its ADAP waiting list. A $215 million 2006 state funds shortfall, and CMS’ decision to disallow county hospital, clinic & nursing home budgets as state matching funds, which will cost the state $100 million, led it to get CMS approval for: limits of 4-Rx’s-a-month, 15 occupational/physical/speech therapy visits-a-year & 12 x-rays/MRIs-a-year (with appeals allowed), $2 to $10 co-pays for doctor visits, $2 to $20 co-pays for other outpatient care, $10 to $20 co-pays for non-emergency ER visits, a whopping $20 to $50 co-pay per hospital stay ; annual cost-sharing caps of $225 a person & $350 a family (except for non-Louisville-area patients, who’ll be put into an HMO with a $450 cost-sharing cap); and co-pays of $3 per generic, $10 for “preferred” & $22 for “non-preferred” brand name Rx’s for spend downers. There will be 4 Medicaid groups: “healthy” adults; children; aged & disabled adults (including LTC & HCB patients); and the mentally retarded & developmentally disabled—each with its own benefits & different, but higher, cost-sharing. See http://www.kff.org/7530.cfm for details. The state settled a lawsuit by starting to move 2,500 disabled into HCB care and raised children’s dental rates by 30% to keep & attract providers.

Louisiana---the state cut allowed Rx’s to 8 monthly (over-ride-able if a doctor certifies medical necessity), cut its Charity Hospital & school health services, adopted a formulary and had to take ADAP cost-containment steps. CMS dropped its claim for a return of $340 million in past matching funds due to questionable accounting. Hurricanes Katrina & Rita cut state revenues ($1 billion+ for 2005-06 in a state study; $1 to $3 billion+ in a federal estimate); and left the Charity Hospitals without sure funding. The Budget Reconciliation bill offers $2.1 billion to pay LA’s & MS’ Medicaid & uncompensated care at a 100% match; but the state still had to cut its doctor rates by 10%. A state healthcare recovery & expansion board is planning a Medicaid “re-design”; asked for $400 million in federal funds to restore New Orleans healthcare (see http://www.dhh.louisiana.gov/offices/page.asp?ID=288&Detail=7198 for the state health director’s comments); aims to expand coverage (Gov. Blanco [D] favors the MA plan); yet also to raise cost-sharing. But, estimating just the added state costs at $200 million, CMS won’t approve or encourage plans for even more federal funds. The state offers Medicaid to the working “pre-disabled” with mental illnesses (as well as all the working “fully” disabled)

Maine---the state subsidizes health insurance for small employers’ workers & dependents; raised the Medicaid level for the childless--aged, disabled or not--to 125% (but then barred new childless, non-disabled, non-aged applicants) & for parents to 200%; planned coverage of the working disabled; has a waiver to offer limited Medicaid benefits to HIV+ persons (including the “pre-disabled”) under 250%; and adopted a formulary (with physician over-rides allowed). When the health budget faced shortages, the state raised taxes on the rich, tobacco, alcohol, hotels, car rentals & restaurants to fund health care; caught up on backlogged provider payments; but set up a board to study ways to cut Medicaid costs.

Maryland---outgoing Governor Ehrlich (R ) closed CHIP to new patients with incomes over 200% ; raised its premiums; and tried to end Medicaid & CHIP for legal immigrant children & pregnant women here less than 5 years (but the state supreme court upheld a lower court order secured by Legal Aid banning the cut under the state constitution’s equal protection clause). An AARP/Legal Aid suit claims the state’s HCB waiver medical admission rules are too strict. The higher income SPAP excludes the disabled & now covers only Part D premiums; while the lower income SPAP—and a prior state program offering only outpatient primary clinic care--were re-packaged as a Medicaid waiver covering any adult not on Medicare under 116%. Specialist & dentist rates are too low to attract enough providers. The state started a risk pool (with premium discounts for the poor) & offered Medicaid to the working disabled. But in 2005 a state insurance board let small firm health plans covering 450,000 persons drop meaningful drug coverage. The Democratic legislature overrode Ehrlich’s veto of a tax on firms spending les than 8% of revenue on workers’ health insurance (the state is appealing its voiding by a federal court). A state study board & incoming Gov. O’Malley (D) are considering a “MA-lite” coverage expansion (wider Medicaid eligibility plus an “individual” insurance mandate & small employer incentives).

Massachusetts---almost all of outgoing Gov. Romney’s (R ) health cuts (see http://www.kff.org/medicaid/7378.cfm & http://www.kff.org/medicaid/7314.cfm for details) were killed by the Democratic legislature. He restored dental care for women who are pregnant or have children under 3, but called for tougher work rules even for disabled welfare clients awaiting SSA disability decisions; limited state-funded “Free Care” patients to low income clinics; and imposed $3 clinic & generic drug and $5 ER & brand name drug co-pays on them. Yet he signed a bill to expand Medicaid; require all residents to be insured; enact incentives & subsidies to foster employer coverage; subsidize health insurance for those under 300% (sliding scale premiums per adult will be $18 to $106 monthly); raise the CHIP level from 200% to 300% (open, with higher premiums & cost-sharing, to even “richer” families); restore adult Medicaid dental & eyeglass benefits; raise the parents’ Medicaid level from 133% to 200%; cover more preventative services; offer premium & co-pay discounts to non-smokers & preventive cancer screenees; but the law fails to raise the childless aged (100%) & disabled (133%) levels to equal the new 200% parental levels. CMS approved expansions of Medicaid waivers for the HIV+ (even the “pre-disabled”) & the childless, non-disabled unemployed; and will continue a waiver for $385 million yearly in DSH funds. But an HHS IG audit says the state wrongly claimed $86 million for children’s targeted case management. See The Massachusetts Health Reform at www.communitycalatyst.org on using the plan as a model for reform in other states.

Michigan--- the state, even with raised tobacco & hospital taxes, still had to end almost all Medicaid adult dental, hearing aid, podiatry & chiropractic care and stopped enrolling new childless non-disabled adults under 100% into its small Medicaid expansion waiver (which doesn’t cover inpatient care). The House named a committee to find more Medicaid cuts and the GOP House & Senate passed bills with more & higher Medicaid & SCHIP premiums & co-pays, which Gov. Granholm (D) called “unprecedented in [their] cruelty”. But she signed a bi-partisan compromise to grandfather-in current recipients; adopt some GOP cost-sharing; impose some stricter eligibility rules for some new applicants only; and even require patient urine tests for smoking & sugary/fatty diets (violators face $10 penalty premiums)--while restoring adult dental care, raising children’s dental rates to private-pay levels & vetoing a 4 year welfare time limit. The SPAP was abolished but Granholm asked CMS for $600 million more in federal funds for a Medicaid waiver to fund subsidized, sliding-scale-premium insurance for the working poor & small firm workers under 200% (to be open at cost to “richer” persons); and the state raised child wellness & adult preventive care rates 30%. The Detroit/Wayne County health agency launched a project to enroll 100,000 new Medicaid & SCHIP patients and Genesee County (Flint) voted to fund a 200% income level for county-subsidized coverage for workers & families not eligible for Medicaid or Medicare (Ingram [Lansing], Muskegon and Wayne [Detroit] Counties already fund similar programs). A court voided a pre-DRA state law to let providers make patients actually pay co-pays, but the GOP state Senate voted to raise cost-sharing still higher.

Minnesota---this 209(b) state raised premiums & co-pays for Medicaid, CHIP & MinnesotaCare (state-subsidized health insurance), cut the latter’s income levels and denied Medicaid & CHIP to legal aliens. While GOP plans to abolish state medical assistance for the childless unemployed & the disabled awaiting SSA disability decisions failed, nearly 30,000 still lost MinnesotaCare. Other previous MinnesotaCare cuts were restored when Gov. Pawlenty (R ) & the Democratic Senate adopted a 75-cents-a-pack cigarette “impact fee”. A court voided a state law letting Medicaid providers deny care or Rx’s to those who don’t make co-pays, yet the state’s ADAP moved to drop patients who don’t make its co-pays . The SPAP was abolished on 1/1/06. But Pawlenty funded a $2.5 million Rx discount plan for uninsured & Part D donut hole patients; $4.5 million more for the state SHIP; and Medicaid for some diagnoses of the working “pre-disabled” and all diagnoses of the “recovered/ex-disabled” and fully disabled. He also called for expanding S-CHIP to 90,000 more children; and will even consider a health insurance mandate (like that of Massachusetts) if part of a larger reform package.

Mississippi---has no spend down; Gov. Barbour (R ) cut the monthly aged/disabled income level from over $1,000 to $603 on 1/1/06 (65,000 lost Medicaid) & cut CHIP eligibility (up to 2,500 children were dropped); and a state board began studying more Medicaid “reforms”. Brand name drugs were cut to 2 monthly plus 3 generics (but HIV patients get 5 brand name drugs; there’s a suit challenging the limits); and, using prior authorization & utilization rules, physical, speech & occupational therapy were cut. While the Budget Reconciliation bill offers $2.1 billion for MS’ & LA’s Medicaid & uncompensated care costs at a 100% match, CMS banned further use of a dubious state funding scheme, forcing Barbour to seek $360 million—later revised to $45 million, then $90 million & finally dropped to zero at least until the 1/07 legislative session-- in new hospital taxes. Newly-required face-to-face interviews for both initial & re-determination applications and stricter document verifications caused the rolls to drop by at least 50,000.

Missouri---a 209(b) state; Gov. Blunt (R ) & the GOP legislature cut the aged/disabled income level from 100% to 85%; ended state medical aid & welfare for those awaiting SSA disability decisions; dropped coverage of the working disabled; cut the parents’ level to 23% from 75% (but a court reinstated those who also qualify in other categories); ended adult dental, podiatry, hearing aid, appliance & eyeglass benefits (but an appeals court let a suit against the denial of catheters, bedrails & other equipment proceed); enacted new & bigger Medicaid co-pays; raised CHIP premiums; made 46,000 more children pay them; denied CHIP to those “able” to get “affordable” work coverage, no matter how costly (20,000 lost CHIP; but then the state exempted families with work plan premiums over 5% of income); and tightened medical rules to get nursing home, HCB & home health care. Yet CHIP co-pays were ended, doctor & nursing homes rates were raised & the SPAP was expanded to cover the disabled (only after their 2 year waits). Blue Cross & a foundation subsidize insurance for Kansas City-area families earning under $30,000. The state’s ADAP had to adopt cost-containments but it restored coverage of eyeglasses & wheelchair items. An 11/06 referendum to raise tobacco taxes to restore some Medicaid cuts & raise the income level toward 200% narrowly failed to pass. Blunt’s staff proposed $38 million in new Medicaid “reforms”: hiring MDs, RNs & “health coaches” as “health care home coordinators”; a pilot program to have 5,000+ recipients sign “independence agreements” to get jobs & go off public health care; a $20 million health insurance subsidy program for low income workers in firms employing 50 or less; re-instating only some disabled who lost Medicaid in 2005; continued benefits for foster children after age 18; raising doctor fees; and somehow covering more poor children. See the critique at www.mobudget.org . (Also, media had reported there’d be more use of assigned primary care physicians, managed care, preventive care incentives & “rewards” of dental & vision care for “compliant” patients). The GOP legislature’s token working disabled Medicaid restoration bill still excludes most SSDI recipients.

Montana---former Gov. Martz (R ) added more & bigger co-pays, restricted nursing home eligibility, cut doctor visits for the aged & disabled to 10 yearly, dropped coverage of some hospice & home health care. But Gov. Schweitzer (D) and the Democratic legislature ended the CHIP waiting list; covered 2,000 more children; created tax breaks & buying pools to help small firms insure workers; want a HIFA waiver to fund a higher CHIP income level to cover 10,000 more children & give barebones Medicaid to 3,000 more adults; raised Medicaid’s family asset level to $15,000 (letting it switch 3,800 children from SCHIP, which has a capped budget, to Medicaid, which doesn’t-- freeing SCHIP slots to cover more uninsured children); and created a SPAP to pay up to $33.11 in Part D premiums for aged and disabled Medicare patients under 200% (but it won’t pay for deductibles, co-pays, coinsurance or drugs not on Part D formularies, nor will it cover the disabled’s 2 year waiting period). The state’s “Passport to Health” & Team Care programs save over $20 million yearly by assigning primary care doctors to patients to reduce ER & hospital costs There’s an ADAP waiting list.

Nebraska----this Title XVI state ended coverage for 15,000 welfare-to-work parents (but a US District Court order voiding much of the cut was upheld in 5/06 by the Circuit Court of Appeals) & childless, non-disabled 19 & 20-year-olds. There’s an ADAP waiting list. The state will pay Part D co-pays for dual eligibles in HCB waiver programs and board & care and group homes. A state board seeks to save Medicaid $72 million a year by making it a “defined contribution” plan & promoting assisted living & HCB waivers over nursing home care (see http://www.hhs.state.ne.us/med/reform/ ).

Nevada---this Title XVI state, with no spend down, raised $1 billion in new taxes to fund Medicaid; added coverage of the working disabled; boosted the pregnant women’s level from 133% to 185%; raised the income level & covered the disabled (including those in the 2 year wait) for its SPAP; will use DSH & CHIP funds, with a HIFA waiver & a CMS risk pool grant, for barebones insurance for small firm workers & families (employers would pay 50% of costs & workers would get a $100/mo premium subsidy); added limited adult dental & vision care; boosted state ADAP funding; raised CHIP premiums; rejected adding Medicaid co-pays for Rx’s & other care; and set up a board to study more reforms.

New Hampshire---a 209(b) state; Governor Lynch (D) expanded SCHIP; added more state funds to ADAP; signed a tobacco tax increase for health care; seeks a $2 million boost in home care rates; will hire case managers to economize on costly cases; and will offer the new HPV vaccine free to all girls under 19. The state still has a stricter-than-SSI “209(b)” Medicaid disability rule (inability to work for at least 4 years) and its ADAP had to adopt cost-containment measures.

New Jersey---in 2001-04 the state had to cut the parents’ income level, drop legal aliens, stop paying hospital bills in its state-only program for those awaiting SSA disability decisions and privatize eligibility determinations for CHIP, FamilyHealth & Medicaid. But by 2005 it began moving the parental level back up to 133% (covering 80,000 more parents), sought a waiver to cover all (even non-disabled) adults under 100%; and will offer at-home/in-the-community care as alternatives to nursing homes. The legislature & Gov. Corzine (both Democratic) passed a compromise budget with a 1% sales tax raise to help bolster Medicaid. A federal audit said $52 million claimed by the state for school health care for special needs students was inadequately documented. Democratic legislative leaders broadly outlined early a future “Massachusetts-lite” health coverage expansion plan to cover the uninsured at a cost of $1.7 billion the first year.

New Mexico—has no spend down; its barebones Medicaid waiver-funded health insurance for uninsured adults under 200% excludes Medicare patients. The state seems to have quietly dropped proposed plan changes & waivers to impose co-pays of $2 per Rx, $5 per office visit, $15 per ER visit & $25 per hospital stay, an “enrollment fee” of $25 & a $10 annual premium; cut coverage of rural transport costs to get Rx’s; end coverage of adult eyeglasses & other medical equipment; and stop coverage for illegal aliens. And Gov. Richardson changed eligibility re-certifications to once instead of twice yearly; raised income levels enough (to 235%) to cover 7,800 more children & 1,200 more pregnant women; and chose a task force to plan expanding coverage (modeled on the MA reforms); raising the Medicaid waiver level to 300% to cover more modest income workers; and giving Medicaid to all (even childless & non-disabled) adults under 100%.

New York---a “Family Health” Medicaid waiver covers parents under 150% & all childless (even non-disabled) adults under 100% except Medicare patients (who must be under the lower SSI/SSP level to get it). State-subsidized “Healthy NY” insurance for workers under 250% excludes part timers & Medicare patients & caps yearly Rx’s at $3,000. The state still excludes the disabled from its SPAP, even though Part D now saves it at least $113 million yearly; began forcing SSI recipients into HMOs; raised FamilyHealth co-pays to $5 for doctors & dentists & to $3 for generic & $6 for brand name Rx’s; raised other Medicaid Rx co-pays to $1 per generic & $3 for brands; capped yearly Medicaid co-pays at $200; set up a formulary allowing doctor over-rides; is starting & seeking a waiver for Medicaid assisted living, chore aide & adult day care instead of costlier nursing homes; requested a waiver extension to keep letting HMOs & clinics enroll patients; but cut the aged/disabled couple income level by $75 monthly. The state makes the City & its counties pay half of non-federal Medicaid costs, but it capped those costs to a 3.5% increase. It raised Family Health ER co-pays to $25; let providers deny services to those who don’t meet co-pays); enacted slightly tighter nursing home rules for asset transfers (but did not tighten living allowances, spousal support & asset rules for home-based & HCB waiver care); funded AIDS day care health centers; set up a foundation to spend $250 million it got from a Blue Cross’ charity-to-profit conversion on access for the poor & preventive care, diabetes, diet & fitness programs; and gave Medicaid to the uninsured (disabled or not!) with colon or prostate cancer under 250% (state-funded for those not “federally”-eligible & open even to patients on Medicare). State law requires hospital bill discounts for those under 300% & bans taking homes for delinquent bills.

North Carolina---covered the working disabled (effective 7/1/07); and increased covered Rx’s from 6 to 8 monthly (with exceptions for 3 or even more additional ones). It abolished (1/1/06) but then resurrected (1/1/07) a SPAP – which again excludes the disabled under 65--for those not eligible for Extra Help with incomes under 175%. CMS forced cuts of $80 million in HCB care & home aides for 5,000 disabled persons. The state will make up $30 million of that with school funds; reorganize financing of public behavioral health; and giver $75 million more to community health centers. The UNC hospital system eased some rules for free indigent care, but now forces up-front cash co-pays on them. Children’s orthodonture & dental rates are too low to attract enough providers. The state makes its counties pay 15% of Medicaid costs but Gov. Easley & the legislature (both Democratic) froze county costs for 2006-07. It increased the ADAP income level from 125% to 200% with $4 million in added state funds; but cut money for kindergarteners’ eye exams by 75%. A federal audit requires the state to refund $15.5 million (plus $90 million more from hospitals) in over-claimed DSH funds.

North Dakota---this 209(b) state set up a Medicaid “reform” commission. Dentists are demanding a raise in rates, which are now so low that few accept Medicaid patients (e.g., only one in the Bismark area).

Ohio---this 209(b) state’s GOP legislature cut the parental income level from 100% to 90% (27,000 lost Medicaid 1/1/06); raised Rx co-pays to $3; slashed the adult dental care budget by 50%; ended adult vision, podiatry & psychologist care; cut secondary payments for dual eligibles; herded all non-Medicare patients into HMOs; slashed $80 million from non-federal Disability Medical Assistance (DMA) for the 15,000+ indigent disabled awaiting SSA eligibility decisions; and let providers refuse service to those who don’t meet co-pays. Yet it created over 2,000 new HCB waiver slots; beefed up its home care programs (which cost one-fifth of nursing homes); and moved 700+ patients into that care. Some GOP legislators even proposed covering the working disabled, but the monthly aged/disabled level is still only $504 (the nation’s lowest); no new DMA applications are being taken; current DMA patients must “prove” they need medical care or lose coverage; and a state audit said $400 million—plus $40 million in overpayments-- could be saved by streamlining and management reforms. Yet the legislature passed a mental health parity bill, which outgoing Gov. Taft may-- but incoming Gov. Strickland will—sign into law; and yearly Medicaid spending dropped over $300 million, bringing calls for restoration of prior cuts and encouraging Srtickland’s plan to subsidize job health plan premiums for the working poor.

Oklahoma---this 209(b) state cut the Medicaid level from 185% to 100% for children over 1 & from 100% to the much lower SSI/SSP level for the aged & disabled, ended the family spend down, re-imposed a “3-Rx’s-a-month” limit and cut the nursing home & HCB waiver income level---but Gov. Henry (D) added coverage of the breast & cervical cancer and working disabled groups. Higher tobacco taxes fund a HIFA waiver to subsidize barebones insurance for 50,000+ workers & spouses, with incomes under 185%, in firms with under 50 workers (Henry hopes to expand the program) ; and the state mental health agency coordinates early intervention & treatment services for at-risk school pupils in 30 counties. The state plans to cut $100 million in fraud & abuse; change Medicaid into a defined contribution plan with a 2^nd(Florida-type) HIFA waiver; offer fewer, “customized”, cheaper benefits; pay premium support instead of secondary, wraparound Medicaid if patients can get work coverage; promote health savings accounts; end private insurance benefits mandates; cut ER & nursing home costs by promoting home, primary, community & clinic care; raise provider fees; and further expand mental health care (with some help from a federal grant). But the state ADAP had to adopt cost-containments.

Oregon---a Title XVI state with no spend down; an anti-tax referendum caused 70,000+ adults to lose coverage via income level cuts & premium raises & ended spend down eligibility for all but transplant & HIV patients (Oregon Health Plan enrollment fell over 50%). The state limited adult dental care; ended adult vision care; limited urban non-HMO hospital days to 18 yearly; created, then expanded, a drug discount plan; but adopted more ADAP cost containment steps.

Pennsylvania---funding shortages limit enrollment for state-subsidized barebones “AdultBasic” health insurance for uninsured adults under 200% (it excludes Medicare patients & has no drug benefit). The state’s SPAP still fails to cover the disabled under age 65, even though Part D may now save it $170 million a year. The state finalized plans for the SPAP to wraparound Part D and pay its premiums & cost-sharing for joint eligibles; proposed---but then chose not to impose--imposed $40+ monthly premiums & more & higher co-pays on Katie Becket waiver children whose families make over $40,000; cut covered inpatient hospital stays to twice a year (but only once yearly for General Assistance patients), inpatient rehabilitation stays to once a year and doctor & clinic visits to 18 a year for men; rejected higher co-pays & monthly numerical drug limits; but may have to adopt ADAP cost containments. Gov. Rendell (D) got $85 million more from state Blue Cross plans for the AdultBasic budget to cover 30,000 of the 120,000+ on its waiting list; but those plans (which are CHIP contractors) were caught wrongly enrolling children in their own costlier $50-premium “Special” plans (which don’t have dental, vision, hearing or drug coverage) instead. The 2007 budget raises hospital, nursing home & HMO contractor rates 4%; gives $5 million to hospital burn units; and funds “universal” SCHIP coverage, with more cost-sharing for “richer” families. Rendell in 1/07 will offer a subsidized coverage plan, with sliding scale premiums, to cover one million more persons. The state offers Medicaid to the working disabled & the working “recovered/ex-disabled”.

Rhode Island---the state has an 185% parental/family income level; added limited coverage of the disabled over 55 to its limited-formulary SPAP and offered Medicaid to the working disabled. Gov. Carcieri (R ) set up a Medicaid “reform” board; proposed dropping 3,000 alien children, tightening eligibility & cutting benefits; yet signed a bill to subsidize insurance for some low-paid workers in small firms (but which also weakened the state’s health insurance mandated benefits law). A state court voided his introduction of $1 & $3 Medicaid drug co-pays without legislative approval.

South Carolina---has no spend down. The state cut Medicaid Rx’s from 4 to 3 monthly; added $40 co-pays for inpatient hospitalizations, $25 for ER visits, $2 for doctor visits, $3 for dentists, $3 for medical equipment & $1 for other providers (Rx co-pays were already $3); and seeks CMS waivers to introduce Medicaid health savings accounts and raise co-pays more (e.g., $5 per Rx, $100 per hospital stay, $25 per outpatient surgery). The SPAP has a 200% income limit; is funded as a Pharmacy Plus Medicaid waiver; excludes the disabled; and now covers all but 5% coinsurance of drug costs for Part D patients after they reach the donut hole (10% coinsurance for those with incomes from 135% to 150%). But its ADAP---which gets only token state funding—now has a growing waiting list (on which 4 patients died in 2006) and is $3 million short. The state will re-impose asset tests for families & children (1 vehicle & 1 home of any value + $20,000) and delayed Medicaid/SCHIP coverage of the new HPV vaccine, although the federal children’s vaccine program can offer it.

South Dakota---has no spend down; plans a high risk health insurance pool & its ADAP had to adopt cost-containments.

Tennessee----ended its Tenncare waiver expansion, dropping 191,000+ aged, disabled, parents & “uninsurable” adults; but no children. Except for pregnant women, children & HIV+ persons, doctor’s visits are limited to 10 yearly, hospital days to 20 & Rx’s to 5 (2 brand names + 3 generics monthly),with $3 or $5 co-pays but with exceptions to the limit for HIV & Hepatitis C & drugs--and now for many but not all drugs to prevent death or hospitalization). The state adopted a formulary; set Medicaid ER co-pays at $5; covered Weight Watchers; and ended methadone coverage. It budgeted $20 million more for low income & county clinics ($5 co-pays) but adopted some ADAP economies. With these savings & $50 million in now-re-programmed federal DSH money, the state will raise Medicaid levels for pregnant women & infants; add hundreds of HCB waiver slots; raise the CHIP income level to 250%; subsidize barebones health insurance (at first only for the working poor, but to be open later to the unemployed aged & disabled--with plan startup delayed until 3/07 & temporarily closed to poor workers with uncooperative employers); revive a high risk pool, with priority for the chronically ill dropped by Tenncare (premiums are $5,700 yearly, with a discount for those under 200% that will still cost the poorest a steep $160 monthly); and sponsor Rx discounts on generics & some but not all brand name drugs for those under 250%. But the new CHIP co-pays are $5 for generic & $20 for brand name drugs; $15 per doctor visit; $50 per ER visit; and $100 per hospital stay---with a 5 Rx monthly limit (except for insulin, diabetic supplies, some mental health drugs--and now for many but not all drugs to prevent death or hospitalization). See www.tenncare.org for details. The state ended coverage of benzodiazepines & barbiturates (even for anxiety, epilepsy, seizures & mental illnesses, over-riding its own Rx board). A Tenncare cut impact study was due in 11/06 at www.researchcouncil.net .

Texas—The state ended its family-only spend down & CHIP coverage of prostheses, physical therapy & private duty nursing; tightened CHIP asset rules; imposed $10 to $20 co-pays for CHIP doctor visits & Rx’s; raised CHIP premiums; imposed a 90 day wait to enroll in CHIP; cut Medicaid home health care; and ended adult chiropractic & podiatry coverage. But a state law denying Medicaid to parents who abuse drugs or alcohol or whose children miss school or checkups was voided by a court. The state set up a Medicaid “reform” board & wants a waiver to force TANF children & families in 8 large counties into HMOs that will spend $109 million less on their care each 2 years, but there are delays in similar HMO startups for the aged, disabled & institutionalized . The eligibility privatization contractor’s service was so poor (122,000 children lost coverage, even though a study said 50%+ of applicants had proper documentation), that the state suspended the contract, asked some of the 2,900 laid-off state eligibility workers to return and gave 28,000 CHIP cases more time to complete forms. The ADAP had to take cost-containment measures, but eased access to Fuzeon; and the legislature restored Medicaid & CHIP mental health, vision & hearing aid coverage & CHIP dental care. A federal court said the state was violating its order for better EPSDT outreach, while the state revoked its family planning contract with Planned Parenthood (because it uses private funds for abortions), and is using inexperienced general clinics instead—even as it got a waiver to offer Medicaid family planning services to all women with incomes under 185%.

Utah---this Title XVI state, with a HIFA waiver, gives barebones Medicaid (no hospital, specialists’, nursing home or home health care; high drug & other co-pays; see http://www.kff.org/medicaid/kcmu030706pkg.cfm for a critique) to all uninsured adults (at first only parents, but now even the childless) under 150% & not on Medicare (but only if they apply during infrequent open application periods); offers regular, full Medicaid to the aged & disabled under 100%; but ended adult coverage of podiatry; audiology; speech, occupational & physical therapy; and vision & dental care. Even with a $1 billion state surplus, the GOP legislature still won’t re-fund the dental and vision benefits (for which Gov. Huntsman [R] then actually had to solicit private donations!); and the legislature also won’t raise doctor fees (now too low to attract enough providers) or add more supportive care for the severely disabled. Huntsman began subsidizing up to $150/mo (plus $100 per child) of the employee share of job health plan premiums for low income workers (beginning with 1,000 cases & possibly expanding to 4,000-9,000), and a study board he set up is considering other—even “Massachusetts-’lite” type-- health coverage expansions, but—contrarily--a legislative committee is again considering further Medicaid cuts (i.e., consolidating eligibility staffing; imposing a budget cap) .The state’s ADAP had to take cost-containment steps and the state is considering adopting a preferred drug list..

Vermont—The Democratic legislature reversed Gov. Douglas’ (R ) elimination of adult dental care. But CMS & the legislature approved his HIFA waiver which, in exchange for $400 million extra to meet a 5 year deficit, forces patients into HMOs, promotes HCB care over nursing homes & tightens up asset transfer bans-- but also caps future federal funds. See http://www.kff.org/medicaid/7540.cfm for details. A new, bi-partisan law cuts family premiums by 50%, raises tobacco taxes and charges $365 to employers that don’t offer health insurance to fund state-subsidized, comprehensive, private health insurance for those under 300% starting in 2007. The state also dropped its former, low unearned income threshold level, which had effectively barred most of the working disabled with SSDI & VA checks from Medicaid.

Virginia---a 209(b) state; in 2004 $1.3 billion in new business & tobacco taxes prevented CHIP & Medicaid cuts; raised hospital, nursing home & dental rates; funded 850 more HCB waiver slots; and covered 100,000 more children. Gov. Kaine (D) authorized Medicaid for the working disabled & a SPAP to pay for cost-sharing & drugs uncovered by Part D plans for HIV+ Medicare patients with incomes under 300%; proposed raising the nursing home PNA by $10, the pregnant woman level from 166% to 200% and pediatric fees by 15%; and named a board to strengthen Medicaid & plan coverage expansion (see http://www.dmas.virginia.gov/ab-mrc_home.htm ). But the GOP legislature still wants to create Medicaid health savings accounts, force more patients into HMOs and raise their cost-sharing. Yet both parties’ legislative leaders & state Medicaid staff want further increases added to recent 30%+ dental & OB/GYN (plus other smaller) fee boosts to keep & attract providers; and the legislature’s separate Medicaid study board called for extra “rewards” (e.g., adult dental services, gym fees) for patients who utilize preventive care or are otherwise “compliant”.

Washington---the state returned to yearly eligibility for children (with required re-determinations thus half as often as before); reinstated legal alien children who’d been dropped in 2002; and expanded Basic Health (state-subsidized barebones insurance for those not on Medicare or Medicaid) by 6,500. The state set up a health access board; dropped plans for children’s Medicaid premiums; restored limited adult dental care; and is using a $14 million federal funds windfall to pay co-pays for Part D Extra Help patients into 2007. Facing a $500 million budget increase for Medicaid & related programs in 2007-09, and a state audit (which the federal IG said was at least partially incorrect) finding $1 billion in past improper Medicaid spending (including $9.5 million in federal funds wrongly spent on illegal aliens’ non-emergency care), Gov. Gregoire (D) will reform administrative & prescription controls; adopt case management for chronic, costly cases; and, with a facility development grant from RWJ & presumably a CMS waiver, soon cover assisted living facility care through Medicaid. King County found $2.4 million to keep 4 money-short low income clinics open, at least until mid-2007, and the state & Group Health Cooperative will significantly lower Basic Health premiums in 2007.

West Virginia---the state adopted a monthly limit of 4 brand name drugs and there’s an ADAP waiting list. The state started a health insurance risk pool yet cut medical equipment, transport, incontinence, & wheelchair supply funds and tightened admission criteria –which it later rescinded—for HCB waiver care (slots dropped from 5,000 to 3,500). Gov. Manchin (D) signed bills passed by the Democratic legislature to offer primary care only (no specialist or hospital coverage) to the uninsured working (but not unemployed) poor for 3 years (but only with employer support) for $1 co-pays at 8 clinics, sponsor cheap, barebones subsidized health insurance for the working poor; and raise the CHIP income level from 200% to 300%--all to be effective in 2007 (yet then sought to delay the CHIP income liberalization for at least a year). The state got CMS approval to assign primary physicians to patients, place them in managed care and offer them an extra “bonus” Medicaid package (“emergent” adult dental care; uncapped drug coverage; preventive, anti-smoking, diabetes, fitness & diet services; etc.). At first enrollment in the extra bonus component will be “voluntary”, and just for non-disabled parents & children (but it might later cover the disabled & aged too) who sign “personal responsibility” contracts--with bonus services denied to non-signers & contract breakers (who’d then face more cost-sharing). See http://www.kff.org/medicaid/7529.cfm , http://www.georgetown.edu , http://www.cbpp.org/5/31-06health.htm , http://content.nejm.org/cgi/content/full/355/8/753 & http://content.nejm.org/cgi/content/full/355/8/756 on plan changes.

Wisconsin---the state began covering illegal aliens’ prenatal & childbirth costs; got its Pharmacy Plus waiver funding its SPAP (it has a 240% income level but still excludes the disabled) extended to 6/30/07; but CMS now wants more proof of its cost neutrality. The state is moving 25% of nursing home patients into cheaper “Family Care” (at-home & HCB waiver care). Gov. Doyle (D) vetoed the GOP legislature’s health savings account bill and wants to raise the parent income level from 185% to 200% (with premiums for those over 150%); let “richer” families enroll at full cost; set up state-sponsored reinsurance to lower premiums & costs (by assuming catastrophic expenses) of small employers’ insurers; and enroll those on SSI (except MR & HCB waiver patients) in managed care unless they individually & expressly seek exemption.

Wyoming---has no spend down and its SPAP is open to anyone under 100% who’s not Medicare-eligible. A state board is considering Medicaid reforms (its interim report, due 10/10/06, is at www.wyominghealthcarecommission.org ). The GOP legislature cut the mental health (including children’s hospital care) and substance abuse budget by nearly half (even though there’s a $1 billion surplus & a Healthy Together chronic case management program saves $30 million yearly); authorized a waiver to give watered-down coverage to CHIP parents under 200% (with higher co-pays but premium-free for those under 133%); and a Katie Beckett waiver for limited services for some mentally ill middle income children.

SOURCES AND RESOURCES:

For the 48 states & DC, the 2006 federal poverty level (FPL) is $9800 yearly ($817 monthly) for one plus $3400 yearly ($283 monthly) for each additional person; see the Asst. Secy. for Plan. & Eval. pages at www.dhhs.gov for AK & HI.

See “State Assistance Programs for SSI Recipients, 2006” (email sherry.barber@ssa.gov for a copy) for states’ Medicaid eligibility rules for SSI recipients and their Section 1616, 1634 or 209(b) arrangements; if they offer--and the amounts of and who administers—SSPs, or State Supplementary Payments (including those for residents of licensed board & care homes); and state-SSA welfare interim assistance reimbursement agreements for indigents awaiting SSI.

See “Medicaid and SCHIP Eligibility for Immigrants” (4/06) at http://www.kff.org/medicaid/upload/7492.pdf on limits for federally-matched Medicaid and SCHIP coverage of both legal and illegal aliens.

See www.kff.org/medicaidbenefits for states’ 2003-04 “optional” coverage of chiropractors, podiatry, dentistry, dentures, orthodonture, eyeglasses, optometry, hearing aids, audiologists, psychologists, prosthetics, medical equipment, hospices and physical, occupational, speech & other therapy, which some states later cut in 2004-05.

See “Outline on State Medicaid Cutbacks & Responsive Advocacy” at www.healthlaw.org for legal rules states must meet to make cuts & legal arguments against them. Guides & arguments to oppose cuts appear at www.familiesusa.org , www.cbpp.org , www.communitycatalyst.org & www.TAEP.org ; and www.communitycatalyst.org has a study on the consumer role in health advocacy & expansion in 16 states and advice for consumer reform advocacy in all states.

See these DRA advocacy guides, at www.healthlaw.org : “The Role of State Law in Limiting Medicaid Changes” for a state-by-state analysis of state statutes on who can change state Medicaid plans (i.e., to raise cost-sharing or reduce benefits), “Q and A: State Medicaid Plans” on preparation & submission rules and procedures for state plan amendments and ”The Deficit Reduction Act of 2005: Implications for State Advocacy” for tips to prevent such plan amendments. See http://www.nachc.com/advocacy/Files/state-policy/model520state520legislationh.pdf and http://www.nachc.com/advocacy/Files/ModelStateLegislation-AppropriationsRiderssr031406_RS-.pdf for a model statute requiring that plan changes/waivers be approved by legislatures & not just by Governors or Medicaid agencies.

See “Waiver Watch” at www.healthlaw.org , “Waiver Tool Box” at www.familiesusa.org, “Coverage Gains Under Recent Section 1115 Waivers” 8/05 at www.kff.org & materials at www.cbpp.org for news & details on state waivers.

See “ADAP Watch” at www.NASTAD.org for the latest details on state waiting lists, cost containment measures & state websites. The “National ADAP Monitoring Report, 2006: Key ADAP Highlights”, Chart 1, pp.1-2, at www.kff.org lists state income levels. See the adjacent full Report for state cost sharing rules& medical criteria and/or prior authorization needed for special or costly drugs. State ADAP formularies are in a 2^nd adjacent document. Email alefert@nastad.org for a chart of state ADAPs’ policies & procedures to coordinate with /wraparound Part D .

States’ August, 2003 cost-sharing, premium & co-pay rules & amounts are in “Medicaid and SCHIP: States’ Premium and Cost Sharing” (03/04) at http://www.GAO.gov/new.items/d04491.pdf ; but there’s more recent drug co-pay data in the “State Medicaid Prescription Drug Reimbursement Chart– March, 2005” at www.ascp.com .

See “Pharmaceutical Benefits Under State Medical Assistance Programs, 2004” (Section 4, pp. 24-46) under “Resources” at www.npcnow.org on state formularies, payments, over-the-counter coverage, prior authorization, prescribing/dispensing limits & drug co-pay amounts & any cumulative co-pay amount caps.

See http://www.ncsl.org/programs/health/SPAPCoordination.htm & http://www.medicare.gov/spap.asp on State Pharmacy Assistance Programs’ (SPAP) eligibility & coverage and how they coordinate with/supplement Part D.

See http://www.medicareadvocacy.org/AlertPDFs/07.21.05.PartDSpeak.full.pdf for a Glossary on Part D; “The New Medicare Drug Benefit: How Much Will You Pay?” at http://www.familiesusa.org/issues/medicare/rx-drug-center/benefit-basics.html for charts on its premiums, deductibles & co-pays/coinsurance--plus income & asset levels--for Extra Help; and http://www.nsclc.org/news/06/08/advexcept_081706.doc for a guide to its exceptions & appeals.

See http://www.epocrates.com (subscription required) for regularly updated formularies for each Part D drug plan.

While Part D displaces Medicaid for most drugs for dual eligibles, those 6 narrow classes of drugs that are specifically excluded by the Part D law can still be covered for them by Medicaid; such state coverage is re-tabulated from CMS surveys at www.medicareadvocacy.org/Part D_ExcludedDrugsbyState.htm (12/1/05 report under “News” icon).

See “Individual Budget-Based Models of LTC’ (1/06) at www.statehealthfacts.org for states’ coverage of HCB waiver, home health, personal care aide & patient-directed home-based care as alternatives to institutionalization.

A list of current (2006) state-set personal needs allowance (PNA) amounts for Medicaid patients in skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) and for residents in state-licensed, State Supplementary Payment (SSP)-funded board and care supervised group homes is available from lsmetanka@nccnhr.org .

See www.healthlaw.org for “ Painless Ways To Deal With State Medicaid Shortfalls” (without cutting eligibility or benefits); state eligibility income levels and rules in “States With..High Aged/Disabled ..Income Levels” and “States With High Parental..Income Levels”; a health and Medicaid policy “Glossary”; State Pharmacy Assistance Programs’ coverage of the disabled & their income levels in “SPAPs, Part D and...the Disabled”; “How States Can Make More Patients Eligible for Pt. D Extra Help at Little or No Net State Cost …”; and an introduction to eligibility for “VA Health..Benefits”.