Alabama: This State imposes its copayment requirements on dually eligible Medicare and Medicaid beneficiaries for services for which the State is asked to pay the coinsurance and/or deductible amount. The State does not require a copayment for physician office visits during which surgical procedures are performed. Any identified copayment requirements are applicable to beneficiaries age 18 and older.
Alaska: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the federal poverty level (FPL) established for the State (which is 25 percent higher than in the 48 contiguous states and the District of Columbia). Beneficiaries in this group with income above the FPL must pay an income-based monthly premium.
Arizona: This State has an approved Section 1115 Waiver from CMS under which it provides services in a program called the Arizona Health Care Cost Containment System (AHCCCS). The program includes an Acute Care program and a companion program for long-term care services (in institutional and alternative residential settings as well as home and community based care) called the Arizona Long-Term Care System (ALTCS). All Acute Care program members, whether receiving care on a fee for service basis or through enrollment in a managed care organization, are eligible for the same array of acute care services. All ALTCS members, whether receiving care on a fee for service basis or through enrollment in a managed care organization, are eligible for the same array of acute and long-term care services. The State includes the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group, as well as certain others, with monthly income above $500 pay an income-based monthly premium. The majority of the State’s Medicaid beneficiaries are enrolled in contracted managed care organizations through which they receive health care services. The copayment requirements shown on the tables apply to all populations as appropriate, although there are populations for which the copayments are waived. Providers are required to obtain prior approval from the AHCCCS Administration for specified services for the fee for service populations or from the State’s contracted managed care organizations for the managed care populations. Major differences in coverage limitations between the Acute Care program and the ALTCS program are noted on the tables.
Arkansas: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group are not required to pay monthly premiums but are required to make a copayment for most services received. These copayment amounts are not reflected on the tables but are generally $10 per service or a percentage of the program’s payment for a particular service. This State also has an approved Section 1115 HIFA Waiver from CMS under which it provides a safety net health benefit package in partnership with employers to parents and spouses of Medicaid and CHIP children and to childless adults and spouses. The individuals must be age 19 through 64 with income at or below 200 percent of the FPL. This population receives a limited benefit package under a plan called ARHealthNetworks, which places limits on services, such as the number of covered prescriptions per month and the number of covered physician office visits and hospital services per year. There is a $100 annual deductible, copayments are set at 15 percent of allowed charges for each covered service and there is a maximum annual benefit of $100,000. The information provided in the tables does not reflect policies applicable to this limited benefit program.
California: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level. Beneficiaries in this group must pay an income-based monthly premium. Irrespective of the amounts shown on the tables, copayments are not required for any service for beneficiaries younger than age 19 or for which the program’s payment is $10.00 or less.
Colorado: This State has an approved Section 1115 HIFA Waiver from CMS, relying on federal CHIP authority, under which it extended Medicaid eligibility to pregnant women with family income at or below 200 percent of the federal poverty level. Any identified copayment requirements are applicable to beneficiaries age 19 and older. Providers may collect multiple copayments, if applicable, on the same date of service, e.g., a hospital could collect a copayment for both an outpatient visit and a laboratory service. Substance abuse treatment for pregnant women can extend up to 12 months post partum if services were initiated prior to delivery.
Connecticut: This State has added the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 200 percent of the FPL pay a monthly premium.
Delaware: This State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to additional low-income adults through savings achieved by implementing a managed care program called the Diamond State Health Plan. This statewide managed care program utilizes both a capitated plan and an enhanced fee for service plan, the latter administered by the State and called Diamond State Partners. Most Medicaid beneficiaries, including the expansion population of adults age 19 and older with income at or below 100 percent of the federal poverty level, are required to enroll in one of the two managed care plans. The expansion population is not entitled to coverage of any services until the effective date of such enrollment. In addition to services provided through the managed care plans, beneficiaries receive certain wrap-around services on a fee for service basis. The wrap-around services covered for the expansion population are generally the same as those available to the Traditional Medicaid population. The tables reflect services available through both the managed care plans and as a wrap-around benefit. The capitated plan may also provide additional services for its members.
District of Columbia: The District has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to additional low-income, non-disabled adults age 50 through 64 with income at or below 50 percent of the federal poverty level (FPL) who are not custodial parents or caretakers of children under age 19. The District has also extended Medicaid eligibility to working disabled adults with HIV/AIDS, permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA); qualified beneficiaries must have income at or below 300 percent of the FPL. The benefit package, managed care delivery system and cost sharing requirements for these beneficiaries are the same as for the Traditional Medicaid population. No premium is required.
Florida: This State has an approved Section 1115 Waiver from CMS under which it is implementing a complete reform of its Medicaid program. The reform was implemented initially in Broward and Duval counties in September 2006 and expanded to Baker, Clay and Nassau Counties in July 2007. The reform requires certain Medicaid eligibility groups to enroll in and receive health care services from specified health plans. The plans are paid a risk-adjusted premium and are required to provide all mandatory and most optional Medicaid benefits, but covered services may vary in amount, duration and scope. The waiver includes a provision for enhanced benefit accounts for beneficiaries practicing healthy lifestyle behaviors, with funds available to purchase additional services or to use toward employer-sponsored insurance premiums. Because the reform authorized under the waiver has only been partially implemented, the tables reflect services available on a fee for service basis for the Medicaid population not yet included under the waiver.
Georgia: In early 2008 this State added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium.
Hawaii: This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extended Medicaid eligibility to a number of previously uninsured individuals and through which care is delivered by managed care organizations. The waiver program, initially called QUEST is now known as QUEST Expanded, or QEx. The waiver has multiple components, for different populations at different income levels and with different health care needs. The program requires monthly premiums from beneficiaries not otherwise eligible for Medicaid, including children. Note that the federal poverty level for Hawaii is 15 percent higher than in the 48 contiguous states and the District of Columbia. Copayments are not required from any beneficiaries. The QUEST Expanded Access (QExA) component covers most aged, blind and disabled beneficiaries and is designed to deliver services, including primary and acute care, nursing facility and home and community-based care, through a managed care system rather than on a fee for service basis. The QUEST-Net and QUEST Adult-Coverage Expansion components of the waiver offer more restrictive benefit packages for adults, which are not reflected on the tables. Services covered under these two components include limited days and visits in the hospital setting, with no coverage for maternity, nursery, rehabilitation or skilled nursing; emergency medical and dental care; limited visits for mental health and substance abuse treatment; and prescription drug coverage based on a strict formulary.
Idaho: This State was one of the first to receive approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005. Idaho has implemented its Medicaid Basic Plan with services designed for healthy children and adults; this plan does not include long-term care, organ transplants or intensive mental health treatment, and most beneficiaries are enrolled in the State’s Primary Care Case Management model of managed care called Healthy Connections. The Medicaid Enhanced Plan provides services designed for beneficiaries with more complex health care needs such as the elderly and disabled and includes long-term care in the institutional and community settings, organ transplants and intensive mental health treatment. Children with higher income enrolled in the Basic Plan are subject to a monthly premium. A third plan, the Medicare-Medicaid Coordinated Plan, provides integrated care for beneficiaries dually eligible for Medicare and Medicaid. The tables do not reflect the coverage variances across plans. This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 500 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 133 percent of the FPL pay an income-based monthly premium.
Illinois: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 350 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 250 percent of the FPL pay an income-based monthly premium.
Indiana: This State has an approved Section 1115 waiver from CMS through which it operates two distinct health insurance products: the Hoosier Healthwise Program for current Medicaid eligible beneficiaries and the Healthy Indiana Plan (HIP) for uninsured adults not currently eligible for Medicaid. The Hoosier Healthwise program provides coverage for children, pregnant women and low-income families; it has multiple components, two of which – for some pregnant women and for undocumented persons – offer limited benefit packages. The State’s Children’s Health Insurance Program (CHIP) benefit is also a Hoosier Healthwise component. The HIP provides a high-deductible health plan and an account styled like a health savings account – called a Personal Wellness and Responsibility (POWER) Account – to uninsured adults including uninsured custodial parents of Medicaid and CHIP children with family income between 22 percent and 200 percent of the federal poverty level (FPL). HIP is also available to uninsured childless adults with family income up to and including 200 percent of the FPL. The Traditional Medicaid Program serves primarily beneficiaries dually eligible for Medicare or eligible for Medicaid through satisfaction of a spend down as well as beneficiaries receiving care in an institution. One other program, called Care Select, is the State’s care management program for Medicaid beneficiaries with chronic illnesses and also includes enrollees in the State’s Home and Community-Based Services waivers. Benefits vary across the programs as do beneficiary cost sharing requirements. The majority of Hoosier Healthwise enrollees as well as beneficiaries in the Traditional Medicaid and Care Select Programs receive full and comparable benefits; only these benefits are reflected on the State’s tables. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 350 percent of the FPL. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. Any identified copayment requirements on the tables are applicable to beneficiaries age 18 and older.
Iowa: The Medicaid program in this state is administered through the Iowa Medicaid Enterprise (IME), which is a collection of approved contracts with proven specialty providers of administrative support services. The contracts are overseen by Medicaid agency staff. Iowa was the first state to take up the Home and Community-Based Services (HCBS) option that allows states to offer HCBS services as a State Plan benefit rather than through a Section 1915(c) Waiver. The state used the option to add case management and habilitation services to a targeted population – persons with a history of mental illness who also meet certain risk factor criteria and have ongoing needs. Iowa has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a number of previously uninsured individuals not otherwise eligible for Medicaid. The waiver program, called IowaCare, covers individuals age 19 through 64 with family income at or below 200 percent of the federal poverty level (FPL), including parents of children receiving Medicaid or CHIP benefits. The program also covers pregnant women and their newborns with family income at or below 300 percent of the FPL if incurred medical expenses for family members reduce available income to the 200 percent level. The program covers children through age 17 diagnosed with serious emotional disabilities and meeting criteria for institutionalization but able to be cared for in the community if net family income is at or below 250 percent of the FPL. All three expansion groups receive a limited benefit package (hospital care, physician services and prescription drugs) and are generally required to obtain services from designated publicly funded providers. Monthly premiums up to five percent of income are required from the first two groups and may be reduced through participation in approved healthy lifestyle activities. Copayments, including a prescription drug copayment ranging between $1 and $3 depending on drug cost, may be assessed for individuals in the first two groups as well. The information provided in the tables does not reflect this limited benefit package. Iowa has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. This State imposes a $1 copayment requirement on dually eligible Medicare and Medicaid beneficiaries for each date of service for which the State is asked to pay the coinsurance and/or deductible amount on a Medicare Part B benefit.
Kansas: This State has added the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the federal poverty level (FPL). Beneficiaries in this group with income above the FPL pay an income-based monthly premium. The copayment requirement for physician services is applicable to and in addition to any amount payable to hospitals for outpatient services. This State imposes a $2 copayment requirement on dually eligible Medicare and Medicaid beneficiaries for each date of service for which the State is asked to pay the coinsurance and/or deductible amount.
Kentucky: This State was one of the first to receive approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005. Kentucky’s KyHealth Choices initiative customizes beneficiaries’ benefits to meet their specific needs. There are four plans included in the initiative. Global Choices (“A” on the tables) includes the standard benefit package with more extensive cost sharing and benefit caps and does not include long-term care; it targets pregnant women and parents, caretaker relatives, recipients of cash assistance through SSI or the state’s TANF (KTAP) program, women with breast or cervical cancer, medically fragile children and children in foster care. This plan also includes the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above the FPL pay an income-based monthly premium. Family Choices (“B” on the tables) is targeted to children, including those eligible for Traditional Medicaid and those covered by both the Medicaid expansion and separate CHIP (called KCHIP in Kentucky); it includes the standard benefit package with no cost sharing for the Medicaid-covered children. Optimum Choices (“C” on the tables) includes the standard benefit package as well as institutional (ICF/MR) and community-based long-term care; it targets persons with developmental disabilities. The fourth plan, Comprehensive Choices (“D” on the tables), targets the elderly and disabled in need of institutional or community-based long-term care; it includes the standard benefit package as well as long-term care services, and also relies on authority in a Section 1915 (c) waiver. Irrespective of the plan, members are subject to copayments for certain services and have both a medical and a pharmacy out of pocket maximum of $225 per year. The plan’s designated letter on the tables notes distinctions in coverage; nuances applicable only to the separate KCHIP are not included. Any identified copayment requirements are applicable to beneficiaries age 18 and older and do not apply to preventive services; beneficiaries eligible for both Medicare and Medicaid are exempt from cost sharing.
Louisiana: Most of this State’s Medicaid beneficiaries receive their care through a Primary Care Case Management model of managed care called CommunityCARE. Adult dental services are generally limited to the Categorically Needy (CN) population and to denture-related services, however pregnant women may also receive specified preventive, restorative and periodontal services as well. This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL) and they meet the established resource limit. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium.
Maine: MaineCare is the name of the health care program in this State that provides coverage for residents living below the federal poverty level (FPL) as well as others with low-income. The Medicaid program is a part of MaineCare as is the State’s CHIP, called CubCare, for which some of its members with higher family income are required to make nominal monthly premiums. Maine has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the FPL. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. Most MaineCare beneficiaries receive their care through a Primary Care Case Management model of managed care but may voluntarily enroll in DirigoChoice, a managed care entity, if they work for an eligible business. The State has an approved Section 1115 HIFA Waiver from CMS under which it extended Medicaid eligibility to childless adults with income at or below 125 percent of the FPL. This population receives a limited benefit package and is not referenced in the tables.
Maryland: This State has an approved Section 1115 mandatory managed care waiver from CMS under which it extended Medicaid eligibility to a number of different populations not otherwise eligible for Medicaid in a program called HealthChoice. This includes offering a limited benefit package of primary care benefits to beneficiaries in the Primary Adult Care (PAC) program for childless adults with income at or below 116 percent of the federal poverty level (FPL). Pharmacy copayments for PAC are set at higher levels than for beneficiaries receiving full benefits. The waiver also includes the State’s expansion population eligible for family planning benefits only. The 1115 waiver allows the State to provide enriched benefits such as therapies, dental care and private duty nursing to certain Medicaid eligible disabled adults in a program called the Rare and Expensive Case Management (REM) program. Services for HealthChoice members are provided primarily through managed care organizations. The State has also added the optional Medicaid buy-in group of working disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 300 percent of the FPL. All of these beneficiaries must comply with applicable HealthChoice copayment requirements and an income-based semi-annual premium is charged for those with income above 100 percent of the FPL. The information provided in the tables does not reflect policies applicable to any limited benefit programs.
Massachusetts:This State’s Medicaid and CHIP programs are collectively called MassHealth. In addition to covering the Traditional Medicaid population, the State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a number of previously uninsured individuals. These waiver-covered groups include low-income workers and their families, working and non-working disabled persons, individuals with HIV/AIDS and women with breast or cervical cancer. The waiver also covers long-term unemployed adults and children in families with income at or below 200 percent of the federal poverty level (FPL) although children between 150 percent and 200 percent of the FPL are generally covered through CHIP, which is not integrated into the Section 1115 waiver. Individuals who are age 65 or older, institutionalized, or enrolled in a Home and Community-Based Services (HCBS) waiver are excluded from the Section 1115 waiver and are covered through the State Plan. In 2006, the State enacted a wide-ranging health reform law designed to increase health insurance coverage for almost all state residents. Key components of the plan include expanding MassHealth coverage to uninsured children under CHIP from 200 percent of the FPL to 300 percent and creating a new program called Commonwealth Care through the Section 1115 waiver that provides sliding-scale subsidies for health insurance to uninsured adults at or below 300 percent of the FPL who are not otherwise eligible for MassHealth or affordable private coverage. Some MassHealth members are required to pay monthly premiums. Copayments for MassHealth members are limited to annual maximums of $200 for prescription drugs and $36 for non-pharmacy services per beneficiary. Commonwealth Care members are also subject to sliding-scale premiums as well as copayments, both of which differ from those for MassHealth members. MassHealth provides premium assistance to purchase employer-sponsored insurance through all of its coverage types. Long-term unemployed individuals, upper-income children and individuals enrolled in Commonwealth Care receive benefit packages that are different from the State Plan. Services for members under age 65 are generally provided by managed care organizations or the Primary Care Clinician Plan. Certain services are paid for outside of managed care contracts on a fee for service basis. Only policies applicable to all populations or related to those services reimbursed on a fee for service basis directly by the State are reflected on the tables. Some service limitations may apply depending on beneficiary age and coverage type.
Michigan: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). Beneficiaries in this group receive full benefits and pay an income-based monthly premium if their annual income is between 250 percent of the federal poverty level and $75,000. The inpatient hospital copayment requirement does not apply to second hospitals receiving a transfer or to readmissions within 15 days of discharge for the same DRG/diagnosis. The physician copayment requirement is limited to specific office visit codes.
Minnesota: This State’s Traditional Medicaid population of categorically and medically needy beneficiaries receives full benefits and is identified on the tables as “A.” Also included is the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These working beneficiaries are allowed to continue Medicaid coverage and receive full benefits irrespective of annual income, however they are responsible for applicable copayments and an income-based monthly premium is required for any beneficiary with income above the federal poverty level (FPL). Minnesota has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a number of previously uninsured individuals with income at or below 275 percent of the FPL, including children, pregnant women and the parents and caretakers of Medicaid and CHIP-eligible children. The program, called MinnesotaCare, requires monthly premiums based on gross family income and is identified on the tables as “B”. MinnesotaCare children and pregnant women receive the same benefits as the Traditional Medicaid population, with no copayments, so are included within the meaning of group “A” on the tables. Parents and caretakers on MinnesotaCare receive a lesser benefit package and copayments apply to this group in two tiers, depending on income. The group with income above 175 percent of the FPL, identified as “B1” on the tables, has higher copayment requirements than the group with lower income however these higher copayment levels are not reflected on the tables.. MinnesotaCare also provides a limited benefit package to childless adults with income at or below 200 percent of the FPL but pays for the services with state funds. All MinnesotaCare beneficiaries receive services through managed care organizations. The reference to specialty drug products under prescription drug reimbursement relates to those drugs used by a small number of beneficiaries with specific complex and chronic diseases, such as HIV/AIDS. Reimbursement rates are negotiated with a limited number of providers.
Mississippi: This State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a select group of the formerly covered Poverty Level Aged and Disabled (PLAD) population after State Plan benefits had been discontinued. This waiver provides full Medicaid benefits to the most needy of the PLAD population, those who are aged and disabled with income at or below 135 percent of the federal poverty level (FPL) and who do not have Medicare coverage. Mississippi was one of the first states to add the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 and subsequently implemented its Demonstration to Maintain Independence and Employment in nine counties of the Mississippi Delta, permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA), for working disabled adults with HIV/AIDS. Beneficiaries in both groups are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the FPL. Monthly premiums are required for those with income above 150 percent of the FPL.
Missouri: This State’s Medicaid program operates as MO HealthNet. Adult coverage for a number of program benefits is limited to pregnant women and those beneficiaries who are blind or are residing in an institutional setting such as a nursing facility. Within federal constraints, any identified copayment requirements are applicable to beneficiaries age 18 and older, except the blind. Beneficiaries eligible for both Medicare and Medicaid are exempt from cost sharing if program payment is limited to coinsurance or deductible amounts. The copayment requirement for physician and related services is applicable to and in addition to any amount payable to hospitals or laboratories for services.
Montana: This State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to individuals age 21 through 64 who are neither pregnant nor disabled and who are parents and caretaker relatives of dependent children. The Basic Medicaid Waiver for Able-Bodied Adults was modeled after the State’s welfare reform demonstration from the mid-1990s and provides mandatory Medicaid benefits as well as a limited package of optional services. Specified services are not covered, including audiology, dental, durable medical equipment, eyeglasses, optometry and ophthalmology for routine eye exams, home infusion, personal care services and hearing aids. However the services are available through the Essentials for Employment program if services are essential to obtaining or maintaining employment, consistent with a typical work-related insurance program. The State provides coverage for emergency dental situations, medical conditions of the eye and certain medical supplies such as diabetic supplies and oxygen. The State’s Traditional Medicaid population is identified on the tables as “A” and the expansion population covered under the waiver is identified on the tables as “B.” Cost sharing requirements are the same for both groups.
Nebraska: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group with income above 200 percent of the FPL pay a monthly premium. Any identified copayment requirements are applicable to beneficiaries age 19 and older. The State does not require a copayment for mental health care, irrespective of the provider of service. The State’s copayment requirements for physicians are not applicable to primary care services and the copayment requirements for nurse practitioners are not applicable to advance practice nurses with specialties in family practice, general practice, pediatrics or internal medicine. The State requires a $1 per visit copayment for physical therapy and a $2 per visit copayment for occupational therapy or speech pathology services rendered in an independent clinic setting but requires a $3 per visit copayment if the services are rendered in an outpatient hospital setting.
Nevada: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits irrespective of annual income, however they are responsible for an income-based monthly premium.
New Hampshire: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 450 percent of the federal poverty level (FPL), however they are responsible for applicable copayments and an income-based monthly premium is required for those with income above 150 percent of the FPL.
New Jersey: This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extended health care coverage to parents and caretaker relatives of Medicaid and CHIP-eligible children with income at or below 200 percent of the federal poverty level (FPL), although this was subsequently reduced to 115 percent of the FPL. The waiver also extended coverage to pregnant women with income between 185 percent and 200 percent of the FPL in a program called NJ FamilyCare. Under the waiver, pregnant women receive full Medicaid benefits and the parents and caretaker relatives receive a reduced benefit package modeled after a standard commercial plan, which is not reflected on the tables. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 500 percent of the FPL however an income-based monthly premium is charged based on income above 150 percent of the FPL. Benefits available to this State’s Medically Needy population are limited as follows. Services in a nursing facility, inpatient psychiatric hospital for persons under age 21, institution for mental diseases, intermediate care facility for the mentally retarded (developmentally disabled) and religious non-medical health care institution are not covered at all, nor is hospice care. Services in the inpatient general hospital setting, as well as chiropractor services and targeted case management are limited to pregnant women. Podiatrist services are limited to pregnant women and the aged, blind and disabled. Prescription drug coverage is available only to pregnant women and children.
New Mexico: This State has added a Medicaid expansion group of children under age 19 through federal CHIP authority if the children are in a family with income between 185 percent and 235 percent of the federal poverty level (FPL). The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 if their income is at or below 250 percent of the FPL. These two groups of beneficiaries receive full benefits but must make copayments for some services. Traditional Medicaid beneficiaries have no copayment requirements. Copayment amounts for the Medicaid expansion beneficiaries are identified on the tables as “A” and copayment amounts for the working disabled buy-in beneficiaries are identified as “B.”
New York: This State has an approved Section 1115 Waiver from CMS under which it implemented The Partnership Plan. The waiver extended health care coverage to low-income adults covered under the former State-funded cash assistance Safety Net program and moved most Medicaid beneficiaries from a primarily fee for service delivery system to a mandatory managed care environment. A subsequent waiver amendment created the Family HealthPlus (FHPlus) program for additional low-income uninsured adults under the age of 65. The benefits package for FHPlus beneficiaries is less comprehensive and requires more and higher copayments for services; the FHPlus benefits and copayments are not reflected on the tables. FHPlus does not include long-term care services for the chronically ill, non-emergency medical transportation, most medical supplies or the majority of non-prescription drugs. Limitations apply to home health, rehabilitation and inpatient and outpatient mental health and substance abuse services as well. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits on a fee for service basis, if their income is at or below 250 percent of the federal poverty level.
North Carolina: This State’s Medicaid program delivers services predominantly through a Primary Care Case Management (PCCM) model of managed care called Community Care of North Carolina. The program is a community-based enhanced PCCM model that brings providers together in networks to manage the health care needs of enrolled beneficiaries. Care is provided on a fee for service basis, copayment requirements are applied uniformly within federal constraints and the program is available statewide. Each year the State legislature establishes visit limits applicable to services rendered by specified practitioners; the limits do not apply to certain physician specialties nor are they applicable to pregnant women or beneficiaries enrolled in a community alternatives program providing home and community-based care.
North Dakota: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA) as well as the optional group of disabled children permissible through the Family Opportunity Act. The adult beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 225 percent of the federal poverty level (FPL) and the disabled children must be in a family with income at or below 200 percent of the FPL. Beneficiaries in both groups are required to pay an enrollment fee of $100 and a monthly premium equal to five percent of their gross countable income. They receive the same benefits as other Medicaid beneficiaries and are subject to the same copayment requirements. Any identified copayment requirements are also applicable to beneficiaries dually eligible for Medicare and Medicaid unless they are institutionalized.
Ohio: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). All identified copayments apply to these beneficiaries, and those individuals with income greater than 150 percent of the FPL are required to pay an income-based monthly premium. Pregnant women are not exempt from the copayments associated with routine eye exams and the fitting of eyeglasses.
Oklahoma: This State has an approved Section 1115 Waiver from CMS under which the SoonerCare program was established to increase access to primary care for members within a partially capitated infrastructure, currently through a Primary Care Case Management model of managed care. The waiver has been amended to extend Medicaid eligibility to a number of previously uninsured individuals, including pregnant women and low-income families with children whose income is at or below 185 percent of the federal poverty level (FPL) as well as disabled children meeting federal Katie Beckett eligibility criteria. All SoonerCare members receive the same services and, within federal constraints, are subject to the same cost sharing requirements. This State imposes a $.50 copayment requirement on dually eligible Medicare and Medicaid members for any service for which the State is asked to pay the coinsurance and/or deductible amount. The information appearing in the tables represents basic SoonerCare adult benefits. Coverage of the benefits is dependent upon the member meeting requirements provided in various state and federal regulations.
Oregon: This State has an approved Section 1115 Waiver from CMS under which it implemented a prioritized list of covered health services for its Medicaid program, called the Oregon Health Plan (OHP), based on their comparative benefit to the population served. Through an amendment to the waiver implemented in 2003 the State extended Medicaid eligibility to a number of previously uninsured individuals. The Traditional Medicaid population, covered under OHP Plus and identified as “A” on the tables for 2004, 2006 and 2008, includes families with income below the federal poverty level (FPL), the elderly, blind and disabled, and pregnant women and children living in families with income at or below 185 percent of the FPL. Also covered under OHP Plus is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA), some of whom are required to pay a monthly premium. The waiver’s expansion population, covered under OHP Standard and identified as “B” on the tables for 2004, 2006 and 2008, includes adults with income below the FPL not eligible for Traditional Medicaid coverage. The benefit package for the OHP Standard program is more limited than for the OHP Plus program. OHP Standard participants who become pregnant are transferred to the OHP Plus program for the duration of their pregnancy and two months post partum. OHP Plus program participants age 19 and older are required to make copayments for specified services if the program makes any payment, even if Medicare or their private insurance covered part of the cost of the service. Imposition of a copayment requirement on the OHP Standard group has been prohibited as the result of a court order, but this population is required to pay income-based monthly premiums if their income is above 10 percent of the FPL.
Pennsylvania: This State’s covered services for the Medically Needy (MN) population are more restrictive than for the Categorically Needy (CN) population. Major differences are identified on the tables. The State has added the optional Medicaid buy-in group of disabled and formerly disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive benefits available for the MN population, if their income is at or below 250 percent of the federal poverty level (FPL). Beneficiaries in this group pay a monthly premium equal to five percent of income except premiums under $10 are not collected. Any identified copayment requirements are applicable to beneficiaries age 18 and older. Adult beneficiaries who are pregnant, are residing in long-term care or other medical institutions or are eligible for Medicaid through the Breast and Cervical Cancer Prevention and Treatment coverage group are exempt from copayment requirements. The copayment amount for x-ray services is also applicable to such services rendered in a clinic, physician office or outpatient hospital setting and may be collected in addition to a copayment required for other services provided.
Rhode Island: This State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a number of previously uninsured individuals. This program, called Rhode Island RIte Care, has several components, for different groups at different income levels. Some benefits are only available to the Categorically Needy (CN) population and the tables reflect this. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 and provides them the full scope of Medicaid (CN) benefits including home health agency-based personal care services. Beneficiaries are required to pay income-based monthly premiums. Services are provided by managed care organizations. Only policies related to those services available to all populations or reimbursed directly by the State are reflected on the tables.
South Carolina: This State has included the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 in its program since 1998. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level (FPL). Qualifying beneficiaries receive services through contracted managed care organizations, most of which offer additional services and do not charge copayments. Any identified copayment requirements are applicable to beneficiaries age 19 and older.
South Dakota: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level. There is no premium requirement and the group is subject to the same copayment requirements as other Medicaid beneficiaries.
Tennessee: This State has an approved Section 1115 waiver from CMS under which it serves two distinct populations under its TennCare program. TennCare Medicaid, identified on the tables as “A,” provides a comprehensive package of covered services with some limitations for adults and nominal copayment requirements for prescription drugs. TennCare Standard, identified on the tables as “B,” provides a similar package of services for adults not meeting criteria for Medicaid eligibility except this group is not eligible for long-term care services. Cost sharing requirements in TennCare Standard vary according to income level. Most TennCare Standard enrollees with income at or above the federal poverty level (FPL) have cost sharing obligations; those with income above 100 percent but below 200 percent of the FPL (identified as B1) have lower copayment obligations than enrollees with income at or above 200 percent of the FPL (identified as B2). All TennCare services with the exception of long-term care are provided through managed care contractors (MCCs): managed care organizations, behavioral health organizations, a dental benefits manager (for children) and a pharmacy benefits manager. MCCs have broad discretion relative to the types of providers they use as long as the providers deliver services within the scope of their licensure and have been appropriately credentialed by the MCC. Within contractual parameters, the MCCs establish their own prior authorization policies, reimbursement methodologies and payment rates. Accordingly, only limitations mandated by the State appear on the tables.
Texas: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the federal poverty level. Beneficiaries in this group are required to pay an income-based monthly premium.
Utah: This State has an approved Section 1115 waiver from CMS under which it provides three different packages of services for its Medicaid beneficiaries. Traditional Medicaid, identified on the tables as “A,” provides a comprehensive package of covered services for primarily children, pregnant women, and the aged, blind and disabled, with some limitations and nominal copayments where permitted under federal law. Included in this category is the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage if their income is at or below 250 percent of the federal poverty level (FPL); they are required to pay a monthly premium and copayments based on an income-based sliding fee schedule. Non-traditional Medicaid, identified on the tables as “B,” provides a smaller package of covered services for certain adults receiving or previously receiving cash assistance through the State’s Temporary Assistance for Needy Families (TANF) program, with some limitations and nominal copayments up to an annual maximum of $500. The Primary Care Network, identified on the tables as “C,” provides a very limited package of covered services for parents of Medicaid-eligible children and other adults with incomes below 150 percent of the FPL, requires a $50 enrollment fee and has higher copayment obligations with an annual maximum of $1,000. The State does not require copayments for any preventive services.
Vermont: This State has an approved Section 1115 waiver from CMS under which it created the Global Commitment to Health. The unique provisions of this waiver cap federal Medicaid contributions at a predetermined level in exchange for State flexibility to redesign its public health care program. The waiver approves designation of the Office of Vermont Health Access, the Medicaid agency, as a statewide public managed care organization. Services are delivered on a fee for service basis or through the State’s Primary Care Case Management model of managed care called Primary Care Plus (PC Plus). Beneficiaries receiving health care coverage through the Vermont Health Access Plan (VHAP), created under previous waiver authority, are included under the new waiver with the exception of those receiving long-term care services, who are covered under a second 1115 waiver called Choices for Care. The State’s Traditional Medicaid population, including low-income families and caretaker relatives and the aged, blind and disabled, as well as optional and expansion populations of pregnant women with income at or below 200 percent of the federal poverty level (FPL), children under age 18 living in families with income at or below 300 percent of the FPL and the working disabled with net income at or below 250 percent of the FPL receive a more generous benefit package (identified on the tables as “A”) than does the VHAP population (identified on the tables as “B”). The working disabled beneficiaries are covered as permitted through the Balanced Budget Act of 1997. The benefit package for the VHAP population is also more generous under PC Plus than under fee for service. Copayments are required for certain services. Income-based premiums are required from some of the expansion populations. In some cases, premiums are reduced if the beneficiaries secure employer-sponsored insurance.
Virginia: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 80 percent of the federal poverty level. No premiums are required.
Washington: This State has an approved Section 1115 waiver from CMS under which it extended Medicaid eligibility to children in families with income above the federal poverty level (FPL) who meet specified eligibility criteria. The waiver provisions permit the State to impose income-based monthly premiums. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 220 percent of the FPL and an income-based monthly premium is paid.
West Virginia: This State has received approval from CMS to implement Medicaid reform permitted by the Deficit Reduction Act (DRA) of 2005 in a program called Mountain Health Choices. The program has a Basic and an Enhanced plan as well as a Traditional Medicaid Plan. The Basic plan (identified on the tables as “A”) includes all state and federal mandatory services and the Enhanced plan (identified on the tables as “B”) offers additional services to members voluntarily signing a health care responsibility agreement. Some of those additional services include weight management, tobacco cessation programs, diabetes education and nutritional counseling and education. West Virginia still offers Traditional Medicaid benefits to some of its beneficiaries (identified on the tables as “C”). This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits under their plan of choice, if their income is at or below 250 percent of the FPL and an income-based monthly premium is paid.
Wisconsin: This State has an approved Section 1115 Waiver from CMS, funded by both Title XIX and Title XXI, under which it extended Medicaid eligibility to families with net income up to 200 percent of the federal poverty level (FPL). Families with income above 150 percent of the FPL pay an income-based monthly premium. This population receives full Medicaid benefits either directly or as a wrap-around for services included in an employer’s insurance package through the BadgerCare Plus Standard Plan. The State has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997. These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below 250 percent of the FPL. Beneficiaries in this group must also pay an income-based monthly premium. A limited benefit package with higher copayment requirements called the BadgerCare Plus Benchmark Plan is available for children and pregnant women with income between 200 percent and 300 percent of the FPL. Under another Section 1115 Waiver the BadgerCare Plus Core Plan is available for childless adults with income at or below 200 percent of the FPL. The Core Plan has a much slimmer benefit package and copayments that are similar to the Standard Plan. The table only reflects characteristics applicable to the State’s full benefit package. Any identified copayment requirements are applicable to pregnant women if the service is unrelated to pregnancy.
Wyoming: This State’s Medicaid program is called EqualityCare and the State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage and receive full benefits if their income is at or below the federal poverty level.
American Samoa: This territory does not determine Medicaid eligibility on a case-specific basis. Instead, a “presumed eligibility” determination is made based on the percentage of the population (not counting illegal aliens) living below the federal poverty level. The calculation is made annually and is currently 87.7 percent. That percentage is applied to the computable costs of providing services, and the territory receives 50 percent of that amount as federal Medicaid financial participation up to a specified ceiling established in law. The Deficit Reduction Act (DRA) of 2005 provided additional funds to the territory, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years will be similarly calculated. As with all states and territories, this territory received a temporary increase in federal Medicaid funding authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. The LBJ Tropical Medical Center is the primary provider of medical services in American Samoa. The territory does not provide the services of either chiropractors or occupational therapists because there are none available.
Guam: Like the other territories, Guam has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. The Deficit Reduction Act (DRA) of 2005 provided additional funds to the territory, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years will be similarly calculated. As with all states and territories, this territory received a temporary increase in federal Medicaid funding authorized by the American Recovery and Reinvestment Act (ARRA) of 2009.
Northern Mariana Islands: The Commonwealth has a single government-controlled and operated hospital and health system that provides the majority of its citizens’ health care services. Like the other territories, the Commonwealth has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. The Deficit Reduction Act (DRA) of 2005 provided additional funds to the Commonwealth, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years will be similarly calculated. As with all states and territories, this territory received a temporary increase in federal Medicaid funding authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. The hospital and health system is paid on a charge basis using Medicare cost ceilings. This methodology is also used for nursing facility services provided off island. For any other services not available through the hospital and health system, providers are paid negotiated rates or the applicable rates paid by the off island Medicaid program.
Puerto Rico: The Commonwealth of Puerto Rico Department of Health, as the single state agency, manages the Medicaid program through an interagency cooperative agreement (contract) with the Puerto Rico Health Insurance Administration (PRHIA), a public corporation. The PRHIA negotiates and contracts with insurers and providers for comprehensive health care coverage for the Medicaid population. This structure operates in accordance with existing Medicaid law and managed care regulations. Like the other territories, Puerto Rico has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. The Deficit Reduction Act (DRA) of 2005 provided additional funds to Puerto Rico, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years will be similarly calculated. As with all states and territories, this territory received a temporary increase in federal Medicaid funding authorized by the American Recovery and Reinvestment Act (ARRA) of 2009. The Commonwealth provides but does not claim federal Medicaid matching dollars for some of the services it provides. Accordingly, although some services are not indicated as a covered benefit on the tables because they are not included in the State Plan, such as Home Health Services, Hospice Care, Medical Equipment and Supplies and Nursing Facility Services, the Puerto Rico Health Insurance Administration makes the services available to Medicaid beneficiaries on an exception basis.
Virgin Islands: Like the other territories, the US Virgin Islands has a federal Medicaid financial participation rate of 50 percent, payable up to a ceiling specified in law. The Deficit Reduction Act (DRA) of 2005 provided additional funds to the Virgin Islands, thus increasing its payment ceiling for fiscal years 2006 and 2007. The ceiling for 2008 was calculated by applying an adjustor, the medical care component of the Consumer Price Index, to the 2007 payment ceiling. The ceilings for subsequent years will be similarly calculated. As with all states and territories, this territory received a temporary increase in federal Medicaid funding authorized by the American Recovery and Reinvestment Act (ARRA) of 2009.
|
