TRUMP ADMINISTRATION INDICATING POTENTIAL LIMITS TO MEDICAID 1115 WAIVER APPROVALS

From the very start of Donald Trump's presidency, he has vowed to grant states the flexibility they need to design their own Medicaid policies. HHS, collaborating with governors and state legislatures, could make dramatic state-by-state modifications to Medicaid using section 1115 waivers allowed under federal law.

Section 1115 waivers give states the possibility to forgo key provisions of federal Medicaid law. The changes made possible by Section 1115 waivers are not as dramatic as those featured in the failed bills. For example, states cannot use 1115 waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to eliminate federal reimbursements for Medicaid expansion; however, they are still significant.

Under the President Trump's administration, CMS has authorized 1115 waivers that the former administration consistently rejected. Many states, for instance, have been allowed to make employment a condition for Medicaid enrollment. (The state of Kentucky; however, is presently in court proceedings over the new policy.).

Trump's administration is likewise allowing Kentucky to require beneficiaries to report income changes while Arkansas is disenrolling beneficiaries for the remainder of the calendar year if they do not comply with the work requirement.

The list below is what CMS has previously declined, as well as what is still under deliberations:

MEDICAID 1115 WAIVERS THAT HAVE BEEN REJECTED BY CMS

Lifetime limits

In May, CMS rejected an 1115 waiver application from Kansas to set up a three-year time limit for people enrolled in the Medicaid program.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said in a statement that she was "... pleasantly surprised by that."

Utah, Wisconsin and Arizona have also sent similar 1115 waiver applications to CMS for lifetime limits, which Alker anticipates will also get rejected.

In a statement by Seema Verma concerning Kentucky's attempt to sanction lifetime limits on Medicaid enrollees, she stated "We seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

Partial expansion

CMS rejected Arkansas' bid to decrease the number of people who qualify for the state's Medicaid program. Arkansas was looking to reduce the eligibility requirement from 138 percent of the federal poverty to 100 percent; however, it was not a firm denial, rather, CMS stated it could not back the waiver application "at this time."

Whenever states vote to expand Medicaid the federal government pays 90 to 100 percent of the program's expenses. If Arkansas were permitted to simply cover people up to 100 percent of poverty, the formerly enrolled members who lose their Medicaid coverage would be eligible for federal health insurance subsidies. This would shift the liability to pay healthcare expenses from the state to the federal government. This scenario is most likely not attractive to the Trump administration.

OTHER 1115 WAIVERS CURRENTLY PENDING

Work requirements for non-expansion states

Besides the denial of permitting lifetime limits on Medicaid enrollees, an additional component of Kansas' 1115 waiver application is still pending; namely, a work requirement. But unlike Arkansas, Indiana and Kentucky, Kansas didn't expand Medicaid by way of the Affordable Care Act (ACA); so demanding individuals to maintain an employment (minimally 80-hours per week) would most likely exclude them for the state's Medicaid program since they would be making too much money.

Oklahoma, Alabama, South Dakota and Mississippi are other states that didn't expand under the ACA exploring work requirements. The Center on Budget and Policy Priorities issued a report that highlights the catch-22 of these proposals.

In the state of Mississippi, for example, a single parent can not earn over $370 per month to receive Medicaid. Nonetheless, if they acquired 20-hour per week employment at minimum wage, they would earn $580 a month, which is too much income to qualify for Medicaid.

"They will be complying with the work requirement but still lose coverage. You're in this situation that can't be fixed," says Jessica Schubel, a senior policy analyst for the Center on Budget and Policy Priorities.

CMS' Verma has stated that she is concerned about this "subsidy cliff" and wants to find a "pragmatic and empathetic" approach to work requirements and other new Medicaid initiatives.

Drug testing for Medicaid enrollment

Finally, last year Wisconsin was the first state to ask for authorization to drug test Medicaid applicants allowing the denial of enrollment if they test positive. Specialists say that there is no way to tell where the federal government will decide the issue. Having said that, CMS has indicated that they would advocate the use of Medicaid funds to cover neonatal abstinence syndrome (a withdrawal ailment that takes place when an infant is born with an opioid addiction from their mother's use during pregnancy). Medicaid experts say it is hypocritical for the federal government to cover babies with drug-related problems but not their parents.

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MEDICAID SCORECARD INTRODUCED BY CMS TO ASSESS PROGRAM'S ADMINISTRATION

The Center for Medicare and Medicaid Services recently released a Medicaid Scorecard to improve transparency and accountability. The scorecard contains care quality data from 2015 statistics provided by participating states, in addition to federally reported information. By combining this data, CMS and the states look to evaluate the performance of Medicaid plans, the program's administration, and outcomes. Any effort to improve efficiencies within the Medicaid program is met with unanimous support across the country; however, industry experts are concerned with the quality of the data used and the underlying purpose of the Medicaid Scorecard.

CMS's preliminary Medicaid scorecard intends to improve state and federal alignment, beneficiary health outcomes, and program administration. It functions to analyze how effectively states are delivering health services to their beneficiaries; at the same time, it takes a look at the timespan it takes for the federal government to authorize waiver requests from the states. The Medicaid Scorecard focuses on three particular areas of measurement:

• State Health System Performance measures "how states serve Medicaid and CHIP beneficiaries across key domains."

• State Administrative Accountability provides "insight into how states and the federal government work together to administer Medicaid and the Children's Health Insurance Program (CHIP).".

• Federal Administrative Accountability provides "insight into how the federal government and states work together to administer Medicaid and the Children's Health Insurance Program (CHIP).".

The Chief of CMS, Seema Verma, views the scorecard as a means of improved accessibility to Medicaid data and the program's care outcomes. Verma declared, "This is about bringing a level of transparency and accountability to the Medicaid program that we have never had before." Over time, CMS says it will make updates to the Medicaid Scorecard enabling it to address additional issues.

The National Association of Medicaid Directors (NAMD) has raised concerns. According to NAMD, "There are significant methodological issues with the underlying data, including completeness, timeliness, and quality." They call into question the quality of the data and what conclusions can be made from it. In their point of view, the data itself is out of date, rendering it an unreliable source to identify a state's performance. Additionally, they point out that any determinations made from the scorecard will be problematic since it compares states with significantly different Medicaid structures.

The Association for Community Affiliated Plans (ACAP) is encouraged by the introduction of a Medicaid Scorecard but also recognizes inconsistencies. The groups CEO, Margaret Murray, sees CMS's initiative as a good start. Murray shared, "we agree with Administrator Verma's note that this is a beginning in terms of how we talk about quality, rather than an endpoint. For one thing, the draft scorecard brings into sharp relief the need for more uniform, consistent data reporting across the Medicaid program."

CMS has recently issued their Medicaid Scorecard with hopes to improve state and federal alignment, beneficiary health outcomes, and program administration; however, Industry experts are calling into question its methodology.

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VIRGINIA LEGISLATURE APPROVES MEDICAID EXPANSION, NOW EYES TURN TO UTAH, IDAHO, NEBRASKA AND MONTANA

After months of deliberation among Republican representatives in both the House and Senate, lawmakers in Virginia voted in support of Medicaid expansion under the ACA on May 30th, 2018. The provision to expand the state's Medicaid program to over 400,000 Virginia citizens was included in the General Assembly's approved budget. Democratic Governor, Ralph Northam signed the bill at the state's capital on June 7th. Virginia will fund the expansion with the aid of a 90% funding from the federal government. According to The Commonwealth Institute, "The new Medicaid coverage would require state contributions totaling $1.02 billion over eight years, resulting in a net savings to the state of $1.06 billion."

The ruling to expand was motivated by two contributing factors. First and foremost, last November, the Republicans were at risk of losing their majority rule due to their resistance to Medicaid expansion. Second, Virginia's growing uninsured population is a strain on the state's ability to provide healthcare to its residents. Since the Affordable Care Act was introduced, the uninsured population has expanded as a result of increasing costs for coverage. Proponents feel that Medicaid expansion will strengthen Virginia's health care system and benefit both program members and people with private insurance. However, critics are worried about the related costs and sustainability of expanding the program.

The vote for Medicaid expansion in Virginia is encouraging news for supporters of other states around the country looking to expand their programs. At the moment, there are four states debating the issue.

Utah - In spite of support from lawmakers for a partial expansion, activists in Utah pulled together the required number of signatures to have a full expansion of Medicaid on the state's November ballot. At this time, polls suggest that over half of the state's voters back expansion.

Idaho - According to healthcare advocates, activists in Idaho have accumulated the required signatures for a ballot initiative. The initiative would allow residents to vote in November on a expansion of the states Medicaid program. At the time of this post, the signatures have been submitted to county clerk's for confirmation by June 30th.

Nebraska - Supporters of expansion in Nebraska have been collecting signatures since April for the Insure the Good Life petition. They will need 85,000 signatures from registered voters by July 5th in order to vote on the matter in November's general election. According to groups collecting signatures, momentum is on the side of Medicaid expansion for Nebraska.

Montana - Montana's Medicaid program is wanting to extend their expansion since it is set to expire in 2019. In order to fund the expansion, a ballot initiative requiring 25,000 signatures has been authorized by the Secretary of State. Unlike other efforts, Montana proposes an increase on taxing tobacco by $2.00 a pack alongside a 33% increase of the wholesale price for tobacco products. At this time, proponents are promoting the initiative and securing signatures.

As Virginia neared its first government shutdown, recently legislatures finalized a state budget that incorporated Medicaid expansion. 400,000 residents will now be eligible to enroll in the program. The choice to expand the program, despite resistance from Republican leadership, could be a good indication as to what will occur in other states seeking to expand this year.

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