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Medicaid Watch: State Medicaid and Health Cuts & Expansions By Thomas P. McCormack  [draft #  29, October 1, 2006; please discard any earlier version]

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. The 2007 Medicaid budget will be short $200 million. 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 waiting period and big deductibles ($1,000; $250 for Rx’s) and co-pays.

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

Arizona---a referendum & waiver gives AHCCES (SCHIP & Medicaid) to all uninsured  parents & children under 200% & to all (even non-disabled) childless adultsunder 100%. CMS agreed, before the DRA’s passage, to let the state set 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 based on income range (only for those with family incomes over 100% FPL) from $45/$85 to $75/$167 monthly. AZ Blue Cross now covers unmarried children of non-group policyholders as dependents to age 29 (!), even if they’re not students.

Arkansas--- Gov. Huckabee (R ) raised $100 million in tobacco & income taxes to save the spend down, Katie Beckett waivers & adult vision care & preserve nursing home rates. Yet  Medicaid & CHIP payments are too low to attract enough doctors & dentists; there’s an ADAP waiting list; and a state committee began studying ways to cut the Medicaid budget. The state got a HIFA waiver to offer barebones, Medicaid-funded health insurance to 50,000 workers & spouses with incomes under 200% ($15 monthly premium; 7 doctor visits & hospital days a year & 2 Rx’s a month; $100 deductible; 15% coinsurance), also offers the plan for a $100 monthly premium to 30,000 more with higher incomes; and raised Medicaid and SCHIP children’s dental rates to 95% of what the private Delta Dental plan pays.  

California---red tape & a lower income level took 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; and got legislative consent to a deal with CMS for $3.3 billion more in DSH federal funds for 5 years (some say it’s too little & doesn’t offer enough state funds). He  made 5% doctor rate cuts & stopped paying extra Medicare HMO premiums for dual eligibles; but supported raising SSP levels to $849 monthly ($1491 a couple); spending $50 million more to expand CHIP;  establishing 500 health clinics in targeted low income schools; banning balance billing to patients for ER visits; and compelling drug makers to offer discounts to the moderate income uninsured. Yet he vetoed the Democratic legislature’s universal coverage bill.

Colorado---has no spend down; a court voided a law to deny benefits to legal aliens & once-blocked CHIP applications are again accepted. Denver’s Medical Center & the University of Colorado Hospital cut their in-house indigent care programs & raised their co-pays. Still, 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% (enough to cover 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% (enough to cover 90,000 more). HIFA waiver plans were dropped, but the state will save $59 million by shifting Medicaid children into HMOs. The legislature, opposed by drug makers & some consumer groups, plans to adopt a drug formulary to save even more. The Colorado Indigent Care plan for those not eligible for Medicaid, such as the childless poor awaiting SSA disability decisions, raised its co-pays: $10 per Rx, $35 per doctor visit, $270 per hospital stay & $15 to $45 per ER visit. The state cut its rates 15% to the ColoradoAccess HMO, which then dumped 65,000 former enrollees into fee-for-service Medicaid; but increased funding for the its health insurance risk pool, allowing more liberal premium discounts for the poor (a 50% discount if family income is under $$40,000; and 40% if under $50,000). 

Connecticut—a 209(b) state; Governor Rell (R ) added doctor co-pays of $1 to $3; raised Medicaid’s $1 Rx co-pays to $1.50 & $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) and forced SAGA patients into HMOs; set up a board to study Medicaid “reforms”; and ended Medicaid coverage of adults’ chiropractic; naturopathy, occupational, physical/ speech therapy & psychology care. But the Democratic legislature raised the parents’ level back up to 150% & repealed Rell’s earlier family & CHIP premium hikes. Medicaid & CHIP specialist & dentist rates are too low to attract enough providers, so the state will raise (only in 2007 and even then just for its first 6 months) most pediatric dental rates to 70% of private insurers’ payment levels. The state offers Medicaid to the working disabled and even the working “recovered/ex-disabled”.

Delaware---has no spend down, ended its waiver to cover all adults under 100% (but still covers parents under 100%) and caps yearly SPAP benefits. Gov. Minner (D) created a Cancer Treatment Program for the uninsured not on Medicare with incomes under 650% (!) & a “CHAP/VIP” state indigent health program for uninsured adults not on Medicare with incomes under 200%; added $5 million for caseload growth; and raised provider rates to 65% of private insurance levels.

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 aged & disabled and 200% for families & children. A “DC Homes” low income clinic expansion plan—now widened by outgoing Mayor Williams (D) to a bigger $240 million proposal, with both its original funding & $33 million in new, windfall tobacco settlement money---will strengthen preventive health, cancer screening, anti-smoking and ER & ambulance services; and expand & add more primary health care facilities. DC also boosted its home health & personal care aide pay rates; added coverage of adult dental care, raised all its dental rates & will subsidize indigent dental care at Howard U. Dental College & low income clinics; and seeks a $7 million CMS grant (with $14 million in local money) to hire more school nurses. CMS let DC raise its QMB & SLMB income levels from 100% & 120% FPL to $1809 monthly each---not only making many more Medicare patients eligible for payment of their Medicare premiums, deductibles & coinsurance, but thereby also for Part D full subsidy Extra Help.

Florida---Gov. Bush (R ) began to outsource Medicaid, welfare & food stamp eligibility to private firms; 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 and also 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 anytime instead of only 2 months a year. Children’s, health , doctor & dentist groups demanded & then sued to raise children’s care fees and made the state drop a prior approval rule for nutrition supplements. The state now plans CHIP cuts of $169 to $219 million; but Dade County & private donors launched a $40 million plan to fund school nurses & social workers to offer preventive & simpler, routine care and enroll potentially eligible 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 (causing some without proper transfer papers to go without coverage) ; ended spend down eligibility for nursing home care (but use of complex trusts can still retain or gain eligibility for some); boosted disease management for chronic cases; dropped adult dental care, orthotics, prosthetics & hospice care; may even time limit eligibility for breast/cervical cancer category patients; 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 ) first sought, then postponed for at least a year, a HIFA waiver 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 adopt 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 state, CMS & hospitals were re-negotiating DSH costs; and---while rising tax revenues may let the state cut less than the $269 to $388 million first projected and the rolls dropped by 60,000 in early 2006 due to tighter eligibility re-determination & document verification procedures---CHIP may still face a $12 million deficit.

Guam—this US territory’s Medicaid matching funds are capped by federal law far below what a state would get. The under-funded non-federal medically indigent program pays even less than Medicaid & attracts even fewer providers. Advocates for private managed care firms claim that letting such contracts with them would save enough money 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 SPAP for aged and disabled patients, but with an income level of only 100%. Gov. Lingle (R) raised the parent income 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 got the Democratic Legislature to pass a hospital tax to fund healthcare. Then they 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 Administrationl VA cuts. But GOP Governor candidate Topinka called for $2.9 billion in Medicaid cuts & stricter eligibility rules for new applicants. To save $1.5 billion projected in a Lewin study, the state began shifting patients into HMOs to fund the expansions (HMO enrollment had been voluntary before).

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 (even though a KPMG audit found many waiver problems). There’s now an ADAP waiting list; and the ACLU filed suit challenging a once-every-6-years-only limit on dentures & relinings. The state plans to spend $1 billion on a privatization of food stamp, welfare & Medicaid eligibility that will close 107 welfare offices with 2,500 workers (now delayed to allow further federal review); tightened its lax spend down procedures (too much & too soon, it turned out, after a class action suit forced the state to accept a court’s consent order reinstating 12,606 aged & disabled who were cut off without even the right to hearings); funded service plans for 650 more disabled clients; is enrolling patients in managed care plans that, doctors say, will pay even less than the pittances Medicaid fee-for-service now does, thus further reducing provider participation and access to primary  and specialist care and inevitably causing unnecessary, costly ER visits; and is considering a Medicaid expansion or HIFA waiver to subsidize (barebones) health insurance for uninsured working adults under 200%, modeled on plans of MA, IA, MI or FL (see http://www.in.gov/fssa/programs/healthcare/affordability for the state’s hearings schedule & issue papers). 

Iowa---the state has a waiver to give watered-down Medicaid (with premiums up to 5% of income) to up to 30,000  uninsured persons 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 was only partially & temporarily served by now-expired extra emergency federal funding and some added state funds. A legislative committee began to study ways to cut Medicaid, but Gov.Vilsack proposed an 80-cent cigarette tax hike to subsidize barebones insurance for even more patients---workers with incomes under 200% who are employed in firms of 25 or less.

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; and even reinstated 2,500 formerly-dropped mentally ill clients. There’s a very long ADAP waiting list. A $215 million state funds shortfall for  2006, 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); reduced or no Rx co-pays for children  & for preventive care; 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.

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) and aims to expand coverage (Gov. Blanco [D] favors the MA plan); but also to raise cost-sharing. The state indefinitely postponed 183,000 cases’ overdue Medicaid eligibility re-determinations & will continue their coverage (unless other states report that clients are now eligible there) until CMS says otherwise. The VA is building a new $1.2 billion New Orleans hospital that also will somehow take on much of the city’s destroyed Charity Hospital workload. 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 income taxes on the rich & on tobacco, alcohol, hotels, restaurants, car rentals & soft drinks to fund health care but also appointed a commission to study ways to cut Medicaid expenses. Systems, red tape, accounting & contactor problems have left the state over one year late in paying many providers.

Maryland---Governor Ehrlich (R ) closed CHIP to new patients with incomes over 200% ; raised its premiums; and  ended Medicaid & CHIP for legal immigrant children & pregnant women here less than 5 years. (which the Democratic legislature reversed---but only effective in 2008). The AARP filed suit saying the state’s HCB waiver medical admission rules are too strict. The higher income SPAP excludes the disabled & now only covers Part D premiums; while the lower income SPAP—and a previous state-funded program offering only outpatient primary clinic care--were re-packaged as a Medicaid waiver covering any non-Medicare-eligible adult under 116%. Specialist & dentist rates are too low to attract enough providers. The state started a health insurance 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 legislature overrode Ehrlich’s veto of a “WalMart” tax on firms that don’t spend at least 8% of revenues on workers’ health insurance—only to have it voided by a federal court (the state is appealing).

 Massachusetts---almost all of Gov. Romney’s (R ) health cut proposals (see http://www.kff.org/medicaid/7378.cfm & http://www.kff.org/medicaid/7314.cfm for details) failed in or were reversed 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  insurancefor 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 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 fees & adult preventive care rates 30%. The Detroit/Wayne County Health Authority began an initiative to enroll over 100,000 new Medicaid & SCHIP eligibles. A court voided a pre-DRA state law to let providers make patients actually pay Rx co-pays, but the 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. Some other previous MinnesotaCare cuts were restored when Gov. Pawlenty (R ) & the Democratic Senate agreed on a 75-cents-a-pack cigarette “impact fee”. A court, using pre-DRA federal Medicaid law, 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 began to drop patients who don’t make its co-pays . The SPAP was abolished on 1/1/06. But the Governor funded a $2.5 million Rx discount plan for the uninsured & Part D donut hole patients; $4.5 million more for the state SHIP; and Medicaid for the working “pre-disabled” and “recovered/ex-disabled” (as well as the working fully disabled).

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. A state study put its Katrina tax losses at $213 to $272 million+ just for 2005’s last quarter. 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 doubtful state funding scheme, forcing Barbour to propose $360 million—later revised to $45 million, then $90 million-- 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 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 the welfare-to-work, disabled or aged categories); ended adult dental, podiatry, hearing aid, crutches, wheelchair maintenance, walker & eyeglass benefits (but a federal appeals court let a suit proceed challenging the denial of catheters, bedrails & other medical equipment to the disabled); enacted new & bigger Medicaid co-pays; raised CHIP premiums, made 46,000 more children pay them; denied CHIP to those seemingly able to get “affordable” work coverage, even if it’s really too costly (20,000 lost CHIP; but a public outcry got the state to exempt 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  (except those in the 2 year waiting period). Blue Cross & a foundation subsidize insurance for Kansas City-area families earning under $30,000. The state’s ADAP had to take cost-containment steps. A state Medicaid “reform” committee called for different benefit packages for families & children, the disabled and the aged; more cost-sharing; and more preventive care  The state Senate---but not the House—voted to restore coverage of the working disabled (but with a very low extra unearned income test that severely limits eligibility); and the state did restore coverage of  eyeglasses & wheelchair supplies. A state poll reports 66% favor a 11/06 referendum (see www.peoplesagendafund.org & www.gromo.org ) to raise tobacco taxes to restore all the Medicaid cuts & raise the Medicaid income level to 200%, which Blunt & GOP legislative leaders oppose. He now refuses to call a special session to complete legislative action on the working disabled restoration bill. A documentary film, Out of Sight, Out of Mind, portrays the cuts’ effects on patients; contact paul@RagTagFilm.com (573) 443-4359 for showings & availability.

Montana---the state 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 found money to end the CHIP waiting list & cover 2,000 more children. 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; and it created tax breaks & buying pools to help small firms insure workers. The state seeks 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 & children non-home asset level to $15,000 (letting it switch 3,800 children from SCHIP, which has a capped budget, to Medicaid, which doesn’t), and thus free those 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 any deductibles, co-pays or coinsurance or for drugs uncovered by Part D plans, nor  cover the disabled in the 2 year waiting period). 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) promoted CHIP enrollment; added $180,000 to ADAP; signed a  tobacco tax increase to fund health costs; is considering a $2 million boost in home care rates; and plans to hire a contractor to “coordinate” & foster cheaper, better care for costly cases. 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 bill with a 1% sales tax increase---but not with the $620-per-bed hospital tax he sought to bolster Medicaid. A federal audit said $52 million in funds that the state claimed for school health care for special needs students was inadequately documented.

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” waiver covers parents under 150% & all childless (even non-disabled) adults under 100% except childless Medicare patients (who must be under the lower SSI/SSP level to get Medicaid). 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 will save it over $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 Medicaid income level by $75 monthly. The state makes the City & its counties pay half of non-federal Medicaid costs, but it capped those local 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 new health foundation to spend $250 million the state got from Empire Blue Cross’ charity-to-profit conversion on promoting access for the poor & preventive medicine, diabetes, diet & fitness programs; and created a new Medicaid coverage category for the uninsured with colon or prostate cancer with incomes under 250% (fully state-funded for those over 150% or otherwise not federally-matchable and reportedly even available secondarily to Medicare patients). State law requires hospital bill discounts for those with incomes under 300% & bans taking homes for delinquent bills. An Assembly study said prior authorization procedures wrongly deny/delay patients’ access to needed walkers, wheelchairs & other medical equipment.  

North Carolina---added coverage of the working disabled (to be effective 7/1/07); increased covered Rx’s from 6 to 8 monthly (with exceptions for serious conditions; 3 more allowed through pharmacists; and even more as allowed by a medication therapy management program); and abolished its SPAP 1/1/06. 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 (with $75 million more for community health centers). The UNC hospital system eased some eligibility rules for free indigent care, but now requires up-front co-pays. 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; authorized doubling the ADAP income level to 250%, if and as federal funding allows (a rise to 200% may be possible); but cut funds 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 established a Medicaid “reform” commission.

Ohio---this 209(b) state 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 the non-federal Disability Medical Assistance (DMA) program for 15,000+ disabled persons 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 home prices) and moved 700+ patients into that care; and GOP majority legislators proposed covering the working disabled. Ohio’s $504 monthly aged/disabled level is already the nation’s lowest. Outgoing Gov. Taft (R ) still wants $2 billion more in cuts & transferred $200 million+ in left-over TANF funds to day care, home energy assistance & other low income programs, but nothing to Medicaid. No new DMA applications are being taken; and current DMA patients must “prove” they need medical care or lose coverage.

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. Gov. 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 primary care and community & clinic care; raise provider fees; further expand mental health care (with some help from a federal grant); allow & fund more nurse practitioner care; and require the covering of students on parents’ private insurance to age 23. But the state ADAP had to adopt severe cost-containments.

Oregon---a Title XVI state with no spend down; an anti-tax referendum caused 70,000+ childless, non-SSI 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%). In 2004-05, the state limited adult dental care; ended adult vision  coverage; limited urban non-HMO in-hospital days to 18 yearly; and 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 could save it $170 million a year (the state is finalizing legislation for the SPAP to wraparound Part D & pay its premiums & cost-sharing for joint eligibles). The state imposed premiums of $40+ monthly plus more & higher co-pays on Katie Becket waiver children whose families make over $40,000. It 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 male adults; rejected higher co-pays & monthly numerical limits for prescriptions; but may have to take ADAP cost containment steps. 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 they (which are CHIP contractors) were caught improperly enrolling children in their own more costly $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. 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 mandated health insurance 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 under 200% after they reach the donut hole (10% coinsurance for those with incomes between 135%  and 150%). But its ADAP---which gets only 4% of its funds from the state—now has a growing waiting list and is $3 million short. The state plans to re-impose asset tests for families & children (1 vehicle & 1 home of any value + $20,000) and has 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, Medicaid doctor’s visits are limited to 10 yearly, hospital days to 20 & Rx’s to 2 brand names plus 3 generics monthly (with $3 co-pays & exceptions for HIV & Hepatitis C drugs). The state adopted a formulary; set Medicaid ER co-pays at $5 (and $5 for some brand name Rx’s); covered Weight Watchers; and ended methadone coverage. It budgeted $20 million more for low income & county clinics (with co-pays of only $5) and  adopted ADAP cost containment measures. But 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 for the working poor (yet most aged & disabled who lost Tenncare can’t work); revive a high risk pool (with premiums of $5,700+ yearly—with further premium subsidy discounts for those under 200% but not for “richer” Medicare patients); 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 illness drugs).See www.tenncare.org for  details & critiques. Yet the state ended Medicaid & CHIP coverage of benzodiazepines & barbiturates (even for anxiety, epilepsy, seizure & mental illnesses, over-riding its own pharmacy committee). Photos & bios of disabled patients who lost Tenncare are at http://www.joonpowell.info/tenncare.html . See www.HealthAffairs.org (4/25/06) for an “Interview With a Tenncare Advocate” [Gordon Bonnyman] for the real reasons for Tenncare’s  “failure” & the cuts.

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 complex hospital rate issues delayed similar HMO contracts for the aged & disabled. The state’s food stamp, welfare & Medicaid privatization contractor’s red tape & service was so poor (100,000 children lost Medicaid or SCHIP since 11/05), that the state suspended the contract, asked some of the 2,900 laid-off state eligibility workers state workers to return and gave 30,000 CHIP cases more time to finish applications & re-certifications. Texas 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. After a federal court first found the state in violation of its order for better EPSDT outreach, a federal appeals court refused to kill the suit that had led to the order. The state revoked its family planning contract with Planned Parenthood (because it uses private funds for abortions), and is using inexperienced general clinics instead. Gov. Perry (R ) & the GOP legislature still refuse to release $256 million collected from surcharges on Texas electric bills meant to pay 10% to 20% of Medicaid & food stamp recipients’ electric bills until the legislature authorizes it in January---and even then may divert the money to fund more Medicaid spending or just shore up the general state budget instead.

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 under 150% & not on Medicare; offers regular, full  Medicaid to the aged & disabled under 100%; but ended adult coverage of podiatry; audiology; speech, occupational & physical therapy, plus vision & dental care. Even with a $1 billion state surplus, the GOP legislature still won’t re-fund the dental and vision benefits (so Gov. Huntsman [R] actually had to solicit private donations to do so!); and the legislature also won’t raise doctor fees (now too low to attract enough providers) or add more special services for the severely disabled. A legislative committee is again looking at ways to further cut Medicaid & other safety net programs .The state’s ADAP had to take cost-containment steps.

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, non-barebones, 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 & appointed a board to strengthen Medicaid & explore coverage expansion (its interim report is at http://www.dmas.virginia.gov/ab-mrc_home.htm ), but the GOP legislature wants to create Medicaid health savings accounts, force more patients into HMOs (half are already) and raise their cost-sharing.

Washington---the state reinstated 12 month Medicaid eligibility for children after over 20,000 lost coverage; dropped legal aliens from Medicaid & CHIP (but later began reinstating many); cut Basic Health (state-subsidized barebones insurance for those not on Medicare or Medicaid) enrollment by 30,000 & raised its premiums & co-pays. Eligibility tightening removed 63,000 patients from Medicaid & CHIP and the state set up a Medicaid “reform” board; but it 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 through 12/06. Facing a $500 million budget increase for Medicaid & related programs in 2007-09, and a state audit 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 tighten 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.

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). A new rule requires prior authorization even for oxygen & breathing machines, as was already true for adult diapers. 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; some extra services; 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 for plan details as first understood; http://www.georgetown.edu & http://www.cbpp.org/5/31-06health.htm on children’s provisions; and http://content.nejm.org/cgi/content/full/355/8/753  & http://content.nejm.org/cgi/content/full/355/8/756 for two NEJM analyses of the state’s Medicaid plan changes.

Wisconsin---the state began covering prenatal & childbirth costs of illegal aliens; got its Pharmacy Plus waiver funding its SPAP (with a 240% income level & which still excludes the disabled) extended to 6/30/07; but CMS now wants better proof of its cost neutrality. The state is moving 25% of nursing home patients into cheaper “Family Care” (at home & in HCB waiver care). Gov. Doyle (D) vetoed the GOP legislature’s health savings account bill; wants to raise the children & parent income level from 185% to 200% (with premiums for those over 150%); and let “richer” families enroll at full cost.

 Wyoming---has no spend down; the state SPAP is open to anyone under 100% --aged, disabled or not---who’s not Medicare-eligible. A state committee is considering more cuts to Medicaid. The GOP legislature cut the mental health (including  children’s hospital care) & 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 parents of CHIP children under 200% (with higher co-pays but premium-free for those under 133%); and a Katie Beckett waiver to offer limited services to mentally ill children in working poor & lower middle income families.  

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, 2005” at www.ssa.gov/policy for states’ Medicaid eligibility rules for SSI recipients; 209(b) status; whether states have (and the amounts of and who administers) any SSPs; medically needy coverage; 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 and legal arguments to oppose them. Guides and policy arguments for opposing state cuts appear at www.familiesusa.org , www.cbpp.org ,  www.communitycatalyst.org  &  www.TAEP.org .

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 & 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  for news & details on state waivers.

See “ADAP Watch” at www.NASTAD.org for the latest details on state ADAP waiting lists, cost containment measures & state ADAP  websites. The “National ADAP Monitoring Report, 2006: Key ADAP Highlights”, Chart 1, pp.1-2, at www.kff.org lists all state ADAP income levels. See the adjacent full Report for their cost sharing measures and any medical criteria and/or prior authorization needed for special or costly drugs.  State ADAP formularies are in a 2^nd adjacent document. See http://www.kff.org/hivaids/upload/7531.pdf for a side-by-side comparing the current Ryan White CARE Act to pending & proposed reauthorization bills;  email weaids@ticann.org for “A Beginner’s Guide to the ADAP Program Crisis.” and email alefert@nastad.org for a chart outlining state ADAPs’ initial responses to an interim survey on their policies & procedures to coordinate with /wrap-around Part D .

States’ 8/ 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 . Also see “Cost-Sharing and Premiums: Shifting Costs to Those Who Can Afford It Least” (2006) at www.familiesusa.org  for opposing excessive state cost-sharing, especially as now allowed by the DRA. 

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 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 of Part D  terms;  “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 Part D premiums, deductibles and co-pays/coinsurance---plus income & asset levels---for Low Income Subsidies(LIS)/Extra Help;  http://www.nsclc.org/news/06/08/advexcept_081706.doc for a guide to Part D exceptions & appeals; and http://www/nsclc.org/news/06/08/compPDPMA_081606.doc to compare  Medicare Advantage (MA)  & individual drug plans’ (PDPs) enrollment, disenrollment & eligibility procedures.      

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 Part D 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) & 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 .

Materials on state TABOR (“Taxpayer Bill of Rights”) state constitutional amendment ballot measures that artificially  restrain and/or reduce state health, social services, public safety & education funding  are available  at www.cbpp.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 & Coverage of the Disabled”;  “How States Can Make More Patients Eligible for Pt. D Extra Help at Little or No State Cost”;  and an introduction to eligibility for “VA Health..Benefits”.