Medicaid Watch: State Medicaid and Health Cuts & Expansions

By Thomas P. McCormack  [draft #  23, July 31, 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. For more 2003-05 details see http://www.kff.org/medicaid/7314.cfm .The state plans to raise doctor payments.

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 with incomes under 200% & to all (even non-disabled) childless adults under 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 depending on income range (but only for those with family incomes over 100% FPL) from $45/$85 to $75/$167 monthly.

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  rates 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), and also offers the plan for a $100 monthly premium to 30,000 more with higher incomes.  

California---red tape & a lower income level has been taking 200,000 parents off the rolls since 2004.  Gov. Schwarzenegger ( R ) called for premiums ($4 to $27) for those with incomes over 100% or the SSI level, is forcing the aged & disabled into HMOs, proposed a yearly patient dental care cap of $1,000 & got legislative consent to a deal with CMS on DSH funding for $3.3 billion more in federal funds for 5 years (but some advocates 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; and banning balance billing to patients for ER visits. A glitch briefly denied Part D benefits to many Kaiser HMO patients and a lower court upheld a San Diego county rule denying spend downs to “over income” cases seeking state/county medically indigent coverage. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm .

 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--which covers those not eligible for  Medicaid, such as those 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 patients into fee-for-service Medicaid. For more 2003-05 details see http://www.kff.org/medicaid/7314.cfm

 Connecticut—a 209(b) state; Governor Rell (R ) raised family Medicaid & CHIP premiums up to $10 to $75 monthly; 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); cut SAGA grants from $350 a month to $200 & forced its 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 the family & CHIP premium increases. Since Medicaid & CHIP specialist & dentist rates are too low to attract enough providers, the state raised (starting only in 2007 & then just for its 1st 6 months) most pediatric dental rates to 70% of private insurers’ payments.

Delaware---has no spend down, ended its waiver to cover all adults under 100% and caps yearly SPAP benefits. Yet 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%. A $5 million+ 2007 budget increase will fund caseload growth and raise 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” plan, with $145 million in DC, federal & private funds, will expand low income clinic care; Mayor Williams (D) proposed raising the child income level to 250%. DC will boost its home health & personal care aide pay rates and will finally cover adult dental care, raise all its dental rates & subsidize indigent dental care at Howard U. Dental College & low income clinics. CMS let DC raised its QMB & SLMB income levels from 100% & 120% FPL to $1809 monthly, not only making many more Medicare patients eligible for payment of their Part B premiums (plus all Medicare deductibles & coinsurance for those made eligible for QMB), but thereby also for Part D full subsidy Extra Help, with co-pays of only $2 / $5 & no deductibles, premiums or donut hole.  DC will spend $250,000 training & paying 75 parents to counsel its public & charter school students about HIV prevention, smoking, obesity, nutrition and fitness.

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; its progress will be followed by the Georgetown U. Health Policy Institute); a waiver pilot starts 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 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 & 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 let a $12 million contract for a private firm to help patients navigate the  Medicaid changes’ complex HMO & other choices in 5 counties and now plans CHIP cuts of $169 to $219 million.

Georgia---the state ended CHIP coverage of oral surgery & other dental work. It 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; ended spend down eligibility for nursing home care (but use of complex trusts can still retain or gain eligibility for some); will start more aggressive disease management for chronic cases & enroll all patients in “Care Management Organizations”; dropped adult dental care, orthotics, prosthetics & hospice care; may even time limit eligibility for breast/cervical cancer category patients; set up a 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 did vote 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 mental health costs for foster children; the state, CMS & hospitals were re-negotiating DSH funding; but rising tax revenues may let the state cut less than the $269 to $388 million first projected.

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; and funds for off-island specialty care, and air transportation to it, are exhausted.

Hawaii—a 209(b) state; a “Quest” waiver gives Medicaid to families & all the uninsured under 200%, except for the  aged & disabled, who must be under 100% to get it. The state requires that employers offer health coverage to employees & dependents and just created a SPAP to supplement Part D for aged and disabled patients, but with an income level of only 100%. Gov. Lingle (R) raised the parent income level from 200% to 250% (covering 29,000 more); lowered CHIP premiums; restored some adult dental care through both Medicaid & dental charity programs (but offered dentures only at one Honolulu/Oahu site, with no transport funding for Neighbor Islanders); and expanded substance abuse treatment.

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 Medicaid/CHIP caseload classes: Parents & children (their care budget will be cut over $13 million yearly, by more cost-sharing or coverage cuts) ; the disabled & chronically ill; and the aged. The first class  (but eventually the others too) will face more cost-sharing & there will be  different (perhaps lesser) benefits for each group, albeit with more preventive care & incentives. See http://healthandwelfare.idaho.gov/site/3629/default.aspx for a state 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 separate Circuit Breaker SPAP, The state did add HIV drugs to that 2^nd formulary (but only for those disabled already on Medicare); raised the family income level to 185%; cut eligibility red tape; and passed a hospital tax to fund Medicaid. Then it raised income levels even higher to cover 253,000 more children ; agreed to a court order raising doctors’, specialists’ & EPSDT rates for children; cut HMO rates by $70 million; and offered subsidized health insurance, for $40 a month, to uninsured veterans who are now ineligible due to Administration VA cuts but are within 25% FPL of  the VA’s Priority Group 8 income level. After a Lewin study projected 5 year savings of  $1.5 billion, the state began shifting patients into HMOs to fund the expansions (HMO enrollment had been 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 (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 privatizing food stamp, welfare & Medicaid eligibility that will close 107 welfare offices with 2,500 workers (now delayed many more months 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 10,000 aged & disabled who were cut off without even the right to hearings); funded service plans for 650 more disabled clients; launched a Back to School program, with help from insurers & HMOs, to boost children’s Medicaid & SCHIP enrollment; and planned a Medicaid expansion or HIFA waiver to subsidize  (barebones) health insurance for some uninsured adults, using Massachusetts, Iowa, Michigan or Florida plans as models. 

Iowa---the state has a waiver to give watered-down Medicaid (with premiums up to 5% of income) to up to 30,000  persons--whether they’re aged, disabled, a parent or not--with incomes under 200% but only at two public hospitals. Yet there’s actually no uniform statewide waiver outpatient drug benefit: Waiver patients 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 only a limited tax credit to expand small employer 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 the  Medicare rate. Blue Cross & a foundation subsidize barebones insurance for Kansas City-area families making under $30,000. The state may have to take ADAP cost containment steps, and is considering higher Medicaid co-pays for smokers & the obese & stricter motorcycle helmet law enforcement and other preventive health measures. Because the state plan limited coverage of disabled institutionalized children to 140/180 days—even though longer stays might be allowed under federal rules—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 and questioned $127 million more in past state 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 Medicaid shortfall for fiscal 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 different benefits & different (but higher) cost-sharing. The state settled a class action suit by starting to move 2,500 disabled patients into HCB care.

Louisiana---the state cut allowed Rx’s to 5 monthly, cut Charity Hospital and school health services, adopted a formulary and had to take ADAP cost-containment steps. CMS dropped its claim to get back $340 million in past matching funds due to questionable accounting. Hurricanes Katrina and Rita cut state revenues ($1 billion+ for 2005-06 in a legislative study; $1 to $3 billion+ in a federal CBO estimate); and left the state Charity Hospitals without sure funding. The Budget Reconciliation bill offers $2.1 billion to pay all LA’s & MS’ Medicaid & uncompensated care costs at a 100% match; but the state still had to cut its already-low doctor rates by 10%. The state is preparing to pick a stakeholder board to begin to plan a Medicaid “re-design” or “waiver”; to rebuild & modernize the Charity Hospitals; to reform long term care; to expand coverage (Gov. Blanco [D] favors the Massachusetts plan); but also to raise cost-sharing. It indefinitely postponed 183,000 cases’ overdue Medicaid eligibility re-determinations and will continue their coverage (unless other states report that they’ve made clients eligible there) until CMS gives it clear guidance. 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.

Maine---the state subsidizes health insurance for small employers’ workers & their families; raised the Medicaid level for the childless--aged, disabled or not--to 125% (but then barred new childless, non-disabled adults) & for parents to 200%; planned coverage of the working disabled; 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.

Maryland---Governor Ehrlich (R ) banned new CHIP patients with incomes over 200% ; raised CHIP premiums; and  dropped coverage 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 to non-Medicare-eligible  adults under 116%--were re-packaged as a Medicaid waiver. Specialist & dentist rates are too low to attract enough providers. The state started a health insurance risk pool (with premium subsidies for the poor) & added Medicaid coverage of 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 big 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 insurance (benefits aren’t yet fully detailed), with sliding scales for those under 300% (premiums range from $0 to $285 monthly); raise the CHIP level from 200% to 300%; again offer adult Medicaid dental & eyeglass benefits; raise the parents’ Medicaid level from 133% to 200%; cover stop-smoking, diet & fitness programs; offer premium & co-pay discounts to non-smokers & preventive cancer screenees; but not raise the childless aged (100%) & disabled (133%) levels. To help fund the plan 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 for two or more years. 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 available at cost to higher income persons). 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 Senate voted to raise cost-sharing still higher. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm

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. But GOP plans to abolish state  medical assistance for the childless unemployed--plus the disabled awaiting SSA disability decisions--and cut 30,000 from MinnesotaCare failed. And some 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 proposed a $2.5 million Rx discount plan for the uninsured & Part D donut hole patients and $4.5 million more for the state SHIP. 

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 (800 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 with an informal, perhaps temporary, exception to allow HIV patients 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-- in new hospital taxes.

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 8%-- later cut to 5%-- of income); and tightened medical rules to get nursing home, HCB & home health care. But 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% support for a referendum (see www.peoplesagendafund.org & www.gromo.org ) to raise tobacco taxes to restore all the Medicaid cuts. Blunt opposes that, and he agreed to call a special session to complete House action on the Senate working disabled restoration bill only if legislative leaders agree on a Medicaid anti-fraud bill too. A documentary, Out of Sight, Out of Mind, shows the cuts’ effects on patients; contact paul@RagTagFilm.com (573) 443-4359 for 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 wants 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. A state board suggested Medicaid savings (by making it a “defined contribution” plan & promoting assisted living & HCB waivers over nursing home care) of $72 million a year (see http://www.hhs.state.ne.us/med/reform/ ). But, while not creating a full-fledged SPAP, the state will pay Part D co-pays for dual eligibles in HCB waiver programs and board & care and group homes. 

Nevada---this Title XVI state, with no spend down, dropped a disregard of unemployment benefits & its plans to end the asset test for pregnant women & children. Yet it 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) in 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 was forced 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 streamlined eligibility red tape, 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%; rejected co-pays for Rx’s & doctor visits; planned to offer at-home/in-the-community care as alternatives to nursing homes by 2008; and set up a state Medicaid Inspector General’s office (which, it’s claimed, could save 10% of program costs). The  legislature & Gov. Corzine (both Democratic) passed a compromise bill with a 1% sales tax increase---but apparently not with the $620-per-bed hospital tax he wanted to bolster Medicaid. A federal audit found that $52 million in federal money which the state claimed in school health services billings 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 and 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 and a $10 annual premium; cut coverage of rural transport costs to get Rx’s; end coverage of adult eyeglasses & other medical equipment; and stop non-emergency coverage for illegal aliens. But Gov. Richardson changed eligibility re-certifications to once instead of twice yearly; raised income levels enough to cover 7,800 more children & 1,200 more pregnant women; and chose a task force to plan even more subsidized health insurance (modeled on Mass.’ reforms); raising the Medicaid level to cover more working poor parents; 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 (to be funded by cutting hospital & nursing home rates, raising Family Health ER co-pays to $25 & letting providers deny services to those who don’t meet co-pays). It also enacted slightly tighter nursing home rules for asset transfers (with a $750,000 home equity ceiling). Yet it did not tighten living allowances, spousal support & asset rules for home-based & HCB waiver care; even  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 & uninsured, supporting community clinics, and 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 now requires sliding scale hospital bill discounts for those with incomes under 300% & bans taking homes for delinquent hospital bills. An Assembly study said obstructive Medicaid prior authorization procedures wrongly deny/delay patients’ access to needed walkers, wheelchairs & other medical equipment. For more 2003-05 details see http://www.kff.org/medicaid/7314.cfm 

North Carolina---cut the pregnant women & infant level from 185% to 151%; added coverage of the working disabled;  cut Rx’s to 5 brand names a month (with unlimited generics); 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 and reorganize & fiscally reform public behavioral health (with $75 million more for community health centers). The state makes its counties pay 15% of Medicaid costs but Gov. Easley (D) & the Democratic legislature froze county costs for 2006-07; apparently funded a doubling of the ADAP income level to 250%; but did not  (as proposed) revive the SPAP to wraparound Part D or set up a risk pool--and cut funds for kindergarteners’ eye exams by 75%.

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; says it got a CMS waiver for Medicaid-funded assisted living facilities for those already in nursing homes or HCB waivers; and covered the working disabled. Ohio’s $504 monthly aged/disabled level is already the nation’s lowest, yet outgoing Gov. Taft (R ) still wants $2 billion more in cuts (e.g., $8 million just in home nursing cuts). He 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 and the state mental health agency coordinates early intervention & treatment services for at-risk school pupils in 30 counties. Henry signed the GOP legislature’s bills  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 & community care; raise provider fees; allow & fund more nurse practitioner care; and cover students to age 23. 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 those plans (which are CHIP contractors) were caught wrongly enrolling children in their own $50-premium “Special” plans--which, unlike CHIP, have no dental, vision, hearing or drug coverage—instead of CHIP. The 2007 budget raises hospital, nursing home & HMO contractor rates 4%;  gives $5 million to hospital burn units; and funds SCHIP coverage for 15,000 more children—but does not finance proposed expansions of the AdultBasic and at-home/in-the-community care programs.

Rhode Island---the state resisted calls to close enrollment or cut the 185% parental income level for RIghtCare (a waivered Medicaid/CHIP expansion); instead it added limited coverage of the disabled over 55 to its formerly aged-only, limited-formulary SPAP & offered Ticket to Work Medicaid to the working disabled. Gov. Carcieri (R ) proposed dropping 3,000 alien children, tightening eligibility, raising cost-sharing & cutting benefits yet also signed a bill to subsidize health insurance for some small firms with low-paid workers (but which pared mandated insurance benefits).

South Carolina---has no spend down. The state raised co-pays for some families on Medicaid & CHIP; cut Medicaid Rx’s from 4 to 3 monthly; added $2 co-pays 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% for those with incomes between 135%  to 150%). But its ADAP---which gets only 4% of its funds from the state—now has a growing waiting list and faces a $3 million shortfall. The state plans to re-impose asset tests for families & children (1 car, 1 home + $20,000).

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

Tennessee----the state ended its Tenncare waiver expansion, dropping 191,000+ aged, disabled & parents with incomes over SSI or TANF levels & “uninsurable” adults; but children are exempt from cuts. Except for pregnant women, children & HIV+ persons, 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; will set ER co-pays at $5 (and even $5 for some brand name Rx’s if CMS agrees); and end methadone coverage. It did offer aged/disabled ex-patients temporary Rx discount cards for up to 55 free generics (plus one brand-name anti-psychotic a month for the mentally ill); budgeted $20 million more for low income & county clinics (with co-pays of only $5) and even covered Weight Watchers. It had to adopt ADAP cost containment steps. But with savings from the cuts & $50 million in former, now re-programmed, federal DSH money, the state will raise income levels for pregnant women & infants; add hundreds of HCB waiver slots; raise the CHIP income level to 250% (to cover 150,00 more children); 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 subsidized premium discounts for those under 200% but not for “richer” Medicare patients); and sponsor Rx discounts on generics & some but not all brand drugs for those under 250%. See www.tenncare.org for  details & critiques. Yet it ended 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” for the real reasons for Tenncare’s  “failure” & the cuts. And see a National Public Radio story on the cuts’ impact in one county at http://www.npr.org/templates/story/story.php?storyid=5491337 .

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. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm. 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. Texas began privatizing food stamp, TANF & Medicaid eligibility work, laying off 2,900 state eligibility workers & closing 100 welfare offices. But contractor red tape & service was so poor (100,000 children lost Medicaid or SCHIP since 11/05), that the state cancelled the contract, asked some 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 court originally found the state in violation of an order for better EPSDT outreach, A federal appeals court refused to kill a suit that has already led a lower court to find the state in violation of an order for better EPSDT outreach.

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 and vision & dental care. Even with a $1 billion state surplus, the GOP legislature still won’t restore the dental and vision benefits (Gov. Huntsman [R] had to solicit private donations to re-fund  them); 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. 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. 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.

Virginia---a 209(b) state; former Gov. Warner (D) got $1.3 billion in new sales, tobacco & business taxes to prevent CHIP & Medicaid cuts; raised hospital, nursing home & dental rates; funded 850 more HCB waiver slots; covered 100,000 more children; and added heart, diabetes & asthma programs. Despite Gov.Tim Kaine’s (D) election, the GOP legislature seeks to create Medicaid health savings accounts, force more patients into HMOs (half are already) and raise 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 will use 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 $95 million in federal funds wrongly spent on illegal aliens’ non-emergency care, but which federal auditors later found to really be only 10% of  that), Gov. Gregoire (D) will tighten administrative & prescription controls; adopt case management for chronic, costly cases; and, with an assisted living facility development grant from RWJ & presumably a CMS waiver, soon cover such care via Medicaid. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm .

West Virginia---State officials called for $3 ER visit co-pays, “health investment accounts” & incentives to deter smoking & reward healthy lifestyles; and adopted a monthly limit of 4 brand name drugs. There’s an ADAP waiting list. A state health insurance risk pool was started but the state cut medical transport, incontinence, medical equipment & wheelchair supply funding & reduced HCB waiver slots from 5,000 to 3,500. Gov. Manchin (D) signed bills to offer primary care only (no specialist or hospital coverage) to the uninsured working (but not to the unemployed aged & disabled) poor for 3 years (but only with employer support) for $1 co-pays at 8 clinics, sponsor an Appalachian Health Plan with cheap, barebones coverage for the working (but not aged & disabled) poor; and raise the CHIP income level from 200% to 300%--all to be effective in 2007. Yet in July, 2006 he sought to delay the CHIP income liberalization for at least a year and a new rule requires prior authorization even for oxygen & breathing machines, as is 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 ancillary services; preventive, anti-smoking, diabetes, fitness & diet services; etc.). At first the extra bonus feature will be “voluntary”, just for non-disabled parents & children (but might later apply to 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.georgetown.edu and  http://www.cbpp.org/5/31-06health.htm for advocates’ analyses of children’s provisions.

Wisconsin---the state made few health program cuts (except small co-pay increases); began covering prenatal & childbirth costs of illegal aliens; and got its Pharmacy Plus waiver funding the Senior Care SPAP (with a 240% income level but which still fails to cover the disabled) extended to 6/30/07, but CMS has now demanded stronger proof of the waiver’s “cost neutrality” on Medicaid costs alone & won’t allow Part D savings resulting from Medicaid’s lower prices to be figured in. The state is moving 25% of nursing home patients into cheaper “Family Care” at home (11,000 are on its waiting list) & HCB waiver care; and letting dental hygienists be independent providers. Gov. Doyle (D) vetoed a GOP health savings account bill and his Healthy Wisconsin plan would raise the family income level from 185% to 200% (but with new sliding scale premiums for incomes over 150% to negate net added costs) and cut the numbers of uninsured.

 Wyoming---has no spend down; the state SPAP (once open to anyone--aged, disabled or not) now covers only non-Medicare eligibles (including those disabled still in their 2 year waiting periods) under an income level of only 100%. A state committee began to study ways to cut Medicaid. In 2006 the GOP legislature cut the mental health (including  children’s hospital care) and substance abuse budget by nearly half (even though the state has a $1 billion surplus & its 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 & 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 . And see especially  “Painless Ways To Deal With State Medicaid Shortfalls” (without cutting eligibility or benefits!) at www.healthlaw.org .

See these new 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 http://www.cbo.gov/showdoc.cfm?index=7033&sequence=0 for Congressional Budget Office estimates of patients to be affected by the 2005 Deficit Reduction Act’s Medicaid cost-sharing & reduced benefit package measures and “Health Centers” under “May News Summary” at www.hrsa.gov on the DRA impact on low income health centers 

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; and  www.HealthAffairs.org ( Vol. 25/No. 2; 4/25/06) for “Ten Medicaid Waivers: HIFA Demonstrations in Ten States” [AZ, CA, CO, ID, IL, ME, MI, NJ, NM & OR] on eligibility expansions with fewer benefits & more cost-sharing for the added patients.

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 Part D coordination & cost sharing measures and medical criteria 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 Comprehensive AIDS Resources Emergency (CARE) Act to proposed reauthorization bills; and email weaids@ticann.org for “A Beginner’s Guide to the ADAP Program Crisis.”.

States’ August, 2003 cost-sharing, premium & co-pay rules & amounts appear 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 . “Cost-Sharing and Premiums: Shifting Costs to Those Who Can Afford It Least” (2006) at www.familiesusa.org is a good, concise advocates’ guide 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 for details about State Pharmacy Assistance Programs (SPAPs) and their adaptations to & arrangements to coordinate with Medicare Part D drug plans.

 See  http://www.medicareadvocacy.org/AlertPDFs/07.21.05.PartDSpeak.full.pdf for a Glossary of Medicare Part D words, terms and acronyms;  “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/Extra Help; and http://www.ucp.org/ucp_generaldoc.cfm/1/9/10020/10020-10020/6655#top for a guide to Part D access & coverage (except Low Income Subsidy/Extra Help eligibility) for the disabled .      

See www.medicare.gov & www.cms.hhs.gov for CMS’ Part D data, enrollment & consumer tools; www.medicarerights.org , www.medicareadvocacy.org ,  www.healthlaw.org & www.TAEP.org on Part D advocacy;

See  http://www.epocrates.com  (subscription required) for regularly updated formularies for each Part D drug plan; and http://www.cms.hhs.gov/center/provider.asp for the CMS-recommended form for physicians to use for Part D plan formulary exception & prior authorization requests (but it can’t be used for high cost  “specialty tier” drugs).

While Part D displaces Medicaid for most drugs for dual eligibles, those 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 www.ncsl.org/programs/health/PartDPatch.htm , “States With Stopgap Measures” at www.healthassistancepartnership.org and http://www.kff.org/medicaid/7467.cfm on states’ emergency drug coverage for dual eligibles whose Part D plans don’t cover their drugs or who have other transition problems.

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.

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 & state income levels in “SPAPs, Part D & Coverage of the Disabled”; and an introduction to eligibility for “VA Health..Benefits”.