Recent State Action on Medicaid Expansion, Work Requirements, and Block Grants
This year, many states have continued to pursue federal approval for a range of proposals affecting Medicaid coverage, such as seeking modifications to the Affordable Care Act’s (ACA) Medicaid expansion or adding Medicaid work requirements.
Currently, nine states have implemented expansion through Section 1115 waivers to impose conditions such as monthly premiums, lock-out provisions for non-payment, and work requirements on certain Medicaid enrollees. While some Medicaid waivers approved by the federal government that include work requirements have faced legal challenges, other states — including those that have not implemented Medicaid expansion — are continuing to seek federal approval to condition Medicaid eligibility on work, with nine additional proposals currently pending.
The following is an overview of some of the current state Medicaid coverage waiver activity and other state actions affecting health coverage, including Tennessee’s recent block grant proposal.
State Changes to Medicaid Expansion Passed by Ballot Initiatives
Earlier this year, Idaho’s governor signed into law a number of changes to the Medicaid expansion ballot measure approved by voters in November 2018. One component of the law required the state to seek a 1332 waiver to enroll individuals eligible for expanded Medicaid who had income between 100 to 138 percent of the federal poverty level (FPL) in subsidized exchange coverage, although these individuals could opt for Medicaid coverage instead. However, in late August the Centers for Medicare & Medicaid Services (CMS) rejected the state’s waiver request, citing that it did not meet the deficit neutrality guardrails required of 1332 waivers. State officials have indicated that they will resubmit the application with additional information, although CMS noted in its letter that even a revised application would likely still not demonstrate compliance with those guardrails. Another aspect of Idaho’s law modifying the voter-approved Medicaid expansion directs the state to seek a waiver to implement Medicaid work requirements for most expansion enrollees, and the state recently submitted this 1115 waiver request for federal approval. If the waivers are not approved by Jan. 1, 2020, the state law requires implementation of traditional Medicaid expansion.
Similar to Idaho, voters in Utah passed a measure last November to implement Medicaid expansion, and in February state legislators enacted a law that significantly alters the voter-approved expansion in a number of ways. The law requires the state to seek a series of waivers, outlined in the state’s implementation toolkit, through a potentially four-step process, depending on what CMS approves. In March, CMS approved the state’s first request — the Bridge Plan — to expand Medicaid to only those earning 100 percent of FPL at the state’s regular federal medical assistance percentage (FMAP) rate, include an enrollment cap if projected costs exceed state appropriations, require individuals with access to employer-sponsored insurance (ESI) to enroll in that coverage with Medicaid premium assistance, and add work requirements in 2020. In May, the state submitted the second waiver proposal for the enhanced FMAP that the ACA provides for the expansion population while keeping the expansion eligibility level at 100 percent FPL, but CMS indicated that it would not provide the enhanced FMAP for a partial expansion. This second proposal also maintains the enrollment cap, work requirements, and ESI premium assistance from the initial waiver, adds in 12-month continuous eligibility and lock-out provisions for non-compliance with certain activities, and notably requests to implement a per capita cap model for receiving federal Medicaid funds for the new eligibility group. Although CMS did not approve the enhanced FMAP for the partial Medicaid expansion, the governor issued a statement that the state would move forward with requesting approval of the other proposal components, and the state submitted the waiver request in late July. If CMS does not approve this per capita cap proposal, the state plans to request permission to implement a “fallback” plan — the third step in the state’s implementation plan — that expands Medicaid to the ACA’s 138 percent of FPL eligibility threshold and provides the state with the enhanced expansion FMAP, and includes work requirements, an enrollment cap, and lock-out provisions. The final option – if this third plan is not approved – is implementing traditional Medicaid expansion through a state plan amendment, as was passed by the voters.
Nebraska was the third state in 2018 to pass Medicaid expansion through a ballot initiative, and while state legislators there did not follow the same route as Idaho and Utah, expansion in Nebraska has not yet occurred because the state intends to seek modifications to the expansion. State officials submitted a state plan amendment for expansion this past April, indicating the state would seek a waiver to modify its existing managed care program to include the expansion population and provide different benefit packages based on whether enrollees complete certain wellness requirements. Expansion will occur no later than Oct. 1, 2020, and the plan eventually will also incorporate work requirements for eligible individuals wishing to remain in the “prime” coverage option, which offers more robust benefits such as dental and vision services.
Activity in Medicaid Expansion States
Montana originally implemented Medicaid expansion through a waiver because the state requires certain individuals to pay premiums. The expansion was scheduled to sunset in July of this year, but in April the legislature passed a bill, signed by the governor in May, to continue expansion that added work requirements for most enrollees. The state’s waiver amendment also seeks to maintain the original waiver’s implementation of 12-month continuous eligibility and modify the monthly premium structure to be based on the amount of time an individual is enrolled. The federal comment period for the waiver amendment recently closed.
In Virginia, Democratic Gov. Ralph Northam and Republican state legislators negotiated a compromise to expand Medicaid with work requirements in 2018. Coverage became effective in January of this year, but the work requirements were not implemented as the state needed to seek federal permission through a waiver. The state is now negotiating to receive federal funding for employment supports, as Northam’s administration has indicated that the state cannot afford to implement the work requirements without these federal dollars. Some Republican state legislators are characterizing the request for this federal funding as an effort to backtrack on the compromise struck last year between them and the governor.
While New Mexico originally implemented the ACA’s traditional Medicaid expansion, the state sought and received approval in December 2018 to add premium and copayment requirements and waive retroactive eligibility for certain expansion enrollees. However, under Gov. Lujan Grisham, the state is now requesting to amend the waiver and remove the copayments, premiums, and waiver of retroactive eligibility.
Activity in Non-Medicaid Expansion States
Like last year, voters in some nonexpansion states will have the chance to consider expansion in 2020. Groups in Oklahoma indicated that they have gathered enough signatures to put expansion before voters in 2020. Medicaid expansion proponents in other states — specifically Missouri and South Dakota — are also attempting to place the issue before voters in 2020. Additionally, in Mississippi’s upcoming gubernatorial election in November, voters will decide between a Republican who opposes expansion and a Democratic who supports it.
North Carolina’s Democratic Gov. Roy Cooper vetoed the state budget in June in part because it did not include Medicaid expansion. However, in mid-September state legislators in the House voted to override the governor’s veto. While the Senate still needs to hold a vote on the veto override, a bill to expand Medicaid with work requirements and premiums has been added back to the legislative calendar.
Georgia is currently drafting two waiver proposals as part of a law signed by the governor in March. The state is expected to submit an 1115 waiver proposal to expand Medicaid to only those earning 100 percent of FPL, as well as seek federal approval through a 1332 waiver to implement a reinsurance program.
Beyond continuing efforts to expand Medicaid or modify laws to do so, block grants have surfaced again. Tennessee has developed a draft proposal to shift federal funding for most of the state’s Medicaid program into a version of a block grant, which would be a significant change and is based on a state law passed earlier this year. Under the plan, the state would receive a capped amount of federal Medicaid funding for low-income parents, children, and individuals with disabilities. Unlike a traditional block grant — which the state acknowledges its plan differs from — the state is requesting additional funding if enrollment rises above a certain threshold, but the funding amount would not be reduced if enrollment declined. Additionally, the funding cap does not include state spending on individuals dually eligible for Medicaid and Medicare, disproportionate share hospital (DSH) payments, outpatient prescription drug expenses, or administrative costs, and any savings achieved from the financing model would be divided evenly between the state and the federal government (the state’s current federal match rate is 65 percent). The state is also requesting additional flexibilities, such as modifying the amount, duration, and scope of benefits without federal approval or public comment and implementing a closed formulary for prescription drugs. The waiver request also proposes to exempt the state from federal regulations for managed care plans. Some policy analysts have identified that federal law does not allow Medicaid’s financing model to be restructured through the 1115 waiver authority, and if CMS does approve the waiver it is expected to face legal challenges. Tennessee also submitted a separate waiver request in December 2018 seeking to implement Medicaid work requirements for low-income parents and caretakers, which is still awaiting federal approval.
Legal Challenges to Medicaid Work Requirements
Medicaid waivers containing work requirements approved by CMS have been halted by court rulings earlier this year in Arkansas, Kentucky, and New Hampshire, and a legal challenge was recently filed against Indiana’s approved work requirements. Earlier this month, a three-judge panel heard oral arguments on the federal government’s appeal of the Arkansas and Kentucky rulings, and the judges noted that the administration had not considered the coverage losses resulting from work requirements. The ruling by this federal appeals court will have significant implications for Medicaid work requirements overall, and while they did not provide specific information about timing for the decision, it is expected before the end of the year. The court challenges are already beginning to have some implications — on Oct. 17, 2019, Arizona informed CMS that it would postpone implementation of the state’s approved Medicaid work requirements due to the litigation in other states. Additionally, a recent study conducted by the Government Accountability Office (GAO) recommended that CMS should improve its oversight of the administrative costs associated with work requirement waivers, which GAO found can be significant, ranging from under $10 million to over $250 million.
In addition to the next round of court decisions on Medicaid work requirements, states are waiting to see if federal guidance on Medicaid block granting will be issued soon — which is currently under review at the Office of Management and Budget. Similar to how states are seeking to implement Medicaid work requirements despite legal challenges, if CMS provides guidance and approves Tennessee’s block grant proposal, other states may also pursue this financing model, even if the block grant is challenged in court. Also, whether CMS and states that have been hesitant to expand will be able to find a middle ground on Medicaid expansion remains a question, and how decisions play out in Idaho and Utah in particular, will be significant for future actions. Similar to this past year, in 2020 states are expected to continue to seek new ways to test the boundaries of Medicaid coverage waivers and manage their Medicaid programs.
For more information about each state’s Medicaid expansion activity, explore NASHP’s map, and for up-to-date information about states’ Medicaid work requirement proposals, review this NASHP chart.
The State of State Health Policy: Governors’ 2016 State of the State Addresses
State of State speeches provide governors with an opportunity to highlight recent policy successes as well as outline key plans and issue areas of focus for the coming year. These speeches are generally strong indicators of governors’ main priorities and sometimes also include specific proposal suggestions and funding recommendations for deliberation by legislatures.
Currently, 31 governors are Republican, 18 are Democrats and one is an Independent. Two states—Kentucky and Louisiana—elected new governors in 2015. So far this year, 40 governors have outlined policy priorities through state of state speeches and/or budget addresses.[1] The chart and descriptions below summarize some of the main health-related themes from these speeches.
See a state-by-state comparison
Six governors mentioned the issue of more broadly addressing population health and building healthy communities.
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Launching Great State 2019 Plan in honor of state’s upcoming 200th birthday; initiative will focus on addressing longstanding problems from healthcare to prison reform and will involve building opportunities for citizens, and promoting education, healthcare, access to technology, job growth and economic opportunity |
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Highlighted poverty’s negative effects and mentioned state’s Two Generation initiative to address poverty that links with the state’s efforts to be the healthiest in the nation; initiative recognizes that residents’ health has economic and overall quality of life impacts; also importance of reducing children’s screen time and the need to promote healthier behaviors such as involvement in outdoor activities |
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Will be investing in issue of homelessness, which will include addressing the needs of the most vulnerable homeless, such as those with chronic health conditions |
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Need to make more coordinated investments and transform towards focusing more intensely on prevention and public health and paying for outcomes rather than volume and services |
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Noted that safe and healthy communities are the foundation of the state; to maintain the state’s high quality of life investments should continue in priorities that support economic growth |
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Mentioned consumer health concerns regarding access to safe and healthy food and the need for meaningful food labeling |
In addition to mentioning health care costs within the context of Medicaid, eight governors also spoke about state health care costs more broadly; often mentioning costs associated with state employee health benefits.
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Noted that state has not allocated enough funding to cover future retiree health benefits for state workers |
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Identified sharply rising health care costs as the state’s biggest challenge, particularly costs of state employee health plans; also importance of shifting from fee-for service health care to a system focused on high quality and affordable outcomes, and ensuring that individuals appropriately use care to help reduce overall costs |
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Commented on the rising costs of mandated health care expenditures for state employees |
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Mentioned state employee health care obligations as one of the state’s biggest fixed expenses, but recent changes to how these obligations are funded will save costs in the future |
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Noted state budget crisis and need for new revenue to avoid severe cuts in assistance programs for disabled individuals and other health programs and potentially having to close safety net hospitals |
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Noted that if state does not address $2 billion budget deficit will have to make significant cuts to basic state services, including health programs such as prescription drug assistance for seniors, services for individuals with mental illness and disabilities, and home and community-based services |
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Mentioned the rising cost of health care as the most significant challenge to the state’s budget and the overall economy as well as creates challenges for families and businesses; noted state’s current work to shift from fee-for-service to an all-payer model focused on better health outcomes and targeted provider spending |
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Commented on the need to reform the administration of state employee health insurance to achieve savings |
In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs.
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Mentioned commitment to implement Medicaid reforms to improve the state’s Medicaid program |
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Noted positive benefits of state’s Medicaid program but that there has been a significant rise in state Medicaid costs; requests legislature consider proposal to restructure taxes on Medicaid managed care organizations |
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Commented that state Medicaid costs have increased from $2.6 billion in FY2013 to $3.1 billion in FY2017 |
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Mentioned plans to move to a Medicaid managed care system to improve care coordination and address significantly rising state Medicaid costs |
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Recent reforms and modernizations to Medicaid program have demonstrated cost savings and also resulted in more client services and increased provider reimbursement rates |
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Access to in-home Medicaid services for individuals with developmental disabilities has significantly improved |
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Noted significant rise in state Medicaid costs |
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Highlighted the success of TennCare as a well-run system with high customer satisfaction ratings |
In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs. Thirteen governors mentioned Medicaid expansion in their speeches. Eight were governors that have not implemented expansion, and five of these governors spoke about the need to expand Medicaid or find another state-specific solution to cover the uninsured (Missouri, South Dakota, Utah, Virginia, and Wyoming). Two governors (Kansas and Nebraska) expressed continued opposition to expansion. Kentucky’s newly elected governor mentioned plans to transform the delivery of publicly assisted health care and to make changes to the state’s traditional Medicaid expansion, although the proposed budget contains funding for expansion in its current form.
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Noted expansion has resulted in greater health coverage for residents and state has benefited from increased federal revenue from expansion |
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Mentioned expansion has resulted in greater health coverage for residents |
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Highlighted the work of cabinet in exploring Medicaid expansion alternatives; also mentioned recently released plan to provide state-funded primary care |
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Mentioned state’s unique expansion program has resulted in increased access to health care and is based on personal responsibility |
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Noted continued opposition to implementing expansion |
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Mentioned plans to transform delivery of publicly assisted health care and to make changes to the state’s current Medicaid expansion; proposed budget contains funding for current expansion |
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Suggested state should act to cover the uninsured through expansion; can develop a state-tailored solution that rewards work and incorporates personal responsibility |
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Noted continued opposition to implementing expansion |
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Urged legislators to support continuation of the Health Protection Program, the state’s Medicaid expansion program, which has increased access to behavioral health services but will end in December 2016 without legislative action |
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Noted opposition to ACA but importance of considering expansion to make the best decisions for the state; current negotiations with federal officials to change reimbursement process for services provided to Indian Health Services enrollees could cover the state’s expansion costs; will not move forward on expansion without legislative budget authority or if any new general funds are needed; also detailed how cost projections for the expansion population were developed; encouraged any expansion legislation to include language to end expansion if the federal match is reduced |
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Noted flaws of ACA but urged legislators to find a state-tailored solution to covering the uninsured |
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Urged legislators to consider Medicaid expansion through a bipartisan, state-tailored solution |
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Noted opposition to ACA overall but that state should craft tailored expansion plan; commented on loss of federal revenue from not expanding affecting hospitals and businesses, and uninsured individuals lacking coverage; cited many organizations that support expansion (e.g. state business alliance and chambers of commerce) |
Two governors spoke about the topic of the ACA’s exchanges in their speeches.
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Mentioned plans to cease operations of the state’s exchange, Kynect, and that individuals will enroll through the federal exchange |
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Noted improvements in eligibility determinations and access to the state’s Health Connector in the past year |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors’ frequently highlighted strategies that have been implemented or that they plan to implement to increase access to behavioral health services.
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Highlighted the issue of drug addiction; plans to convene a group of experts on substance abuse issues, recovering addicts and providers to identify appropriate treatments and reduce barriers to care |
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State is working to improve access to mental health care through State Innovation Model project; also plans to address links between suicide, mental illness and guns |
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State has significantly increased access to substance use treatment and is working with law enforcement to address overdoses; budget includes funding to provide team-based care for individuals in need of intensive treatment services; also plans for the Department of Health and Social Services to work with primary care providers to identify substance abuse issues earlier |
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Mentioned behavioral health issues as the underlying cause of many social, health and economic challenges and that mental health is the most pressing unmet health issue facing the state |
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Local behavioral health crisis centers have been effective; proposed budget includes funding for an additional center |
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Need to increase treatment options for drug addiction; will create task force on enforcement, treatment and prevention; also plans to build the first new mental health hospital in a generation |
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Highlighted the importance of addressing the needs of individuals with severe mental illnesses; will be launching a crisis prevention program for individuals ages 21 to 35 with severe mental illnesses and substance use disorders |
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Recent passage of state laws that increase access to substance abuse treatment; state still needs to “double down” on drug addiction and to treat it as an illness; committed to providing $100 million to improve access to mental health and substance use treatment by providing higher reimbursement rates for services and providers; plans to increase funding for three Accountable Care Organizations focused on providing coordinated physical and behavioral health treatment for Medicaid patients |
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In the past five years the highest amount of funding in the state’s history has been provided for mental health; legislation was passed to reduce prescription drug and substance abuse fatalities |
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Recent investments of over $700 million in the state’s mental health system to restore prior service cuts, but additional focus on the issue is still needed; proposed budget includes funding directed towards building a stronger mental health system |
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Substance abuse has become one of the most significant challenges in the state; have invested in treatment services and resources to publicize services, updated prescription drug monitoring efforts, and implemented other measures to reduce the oversupply of pain medication |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. The issue of heroin and other types of opioid abuse and overdoses were specifically mentioned by a number of governors in their remarks.
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Recently passed state law allowing healthcare providers to make an antidote available to address opioid overdoses and to allow Medicaid to cover inpatient detoxification |
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Plans to address heroin and opioid addiction; proposed budget includes funding for treatment programs and continuation of efforts to monitor prescription drugs |
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State is working to address heroin and opioid addiction through a state-level task force |
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Legislation being developed to address the heroin and opioid abuse epidemic by building capacity in prevention, education, and treatment efforts |
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Need for a prescription drug monitoring program to address the opioid abuse epidemic |
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State has worked to address the heroin and opioid abuse crisis but the issue remains the most urgent public health and public safety concern; efforts are underway to strengthen the state’s prescription drug monitoring program and improve access to treatment, but need further funding for law enforcement and efforts to strengthen prevention, treatment and recovery initiatives |
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Plans to launch a treatment intervention pilot program for individuals recovering from drug overdoses; individuals in recovery will help lead the intervention programs |
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State views opioid overdoses as a public health crisis; aiming to reduce overdoses by one-third in the next three years by investing in treatment, overdose reversals, prevention and recovery |
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State has coordinated trainings for first responders on administering Narcan, an antidote for opioid overdoses; plans to introduce legislation to expand access to Narcan without a prescription |
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Proposing funding to make a pilot program for overdose drug naloxone permanent; also funding for needle exchange programs, additional state staff resources and to develop a new treatment hub |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals, and providing mental health and substance use treatment services rather than incarceration when appropriate.
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Will be focusing on providing drug treatment and counseling to justice-involved individuals to help reduce recidivism |
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Mentioned justice reforms have diverted justice-involved individuals with substance use disorders to treatment rather than incarceration when appropriate |
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Bipartisan commission to reform the criminal justice system recommended enhancing cognitive behavioral therapy and substance abuse treatment programs in the corrections system |
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As part of the state’s justice policy reforms, will be focusing on rehabilitation instead of incarceration and on looking at funding models for drug and mental health courts |
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Proposing $1.6 million to reduce the number of severely mentally ill individuals cycling through jails and emergency rooms and to direct them to treatment instead |
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With reductions in the state’s prison population, one of the correctional facilities has been closed and will be converted into a certified drug abuse treatment facility for justice-involved individuals |
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Importance of addressing the behavioral health issues of justice-involved individuals; proposed budget includes funding for new crisis triage centers, mobile crisis response teams, and community behavioral health clinics |
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State has significantly increased the number of drug and DUI courts; more non-violent justice-involved individuals are receiving community treatment rather than being incarcerated |
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State has increased the number of drug recovery courts, resulting in reduced incarceration costs; proposing to invest more in these courts in order to offer services in all counties |
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Need to address issue of individuals with severe mental illnesses who cycle between jails and emergency rooms; proposed budget includes funding for four new 16-bed crisis triage facilities and three new mobile crisis teams |
Five governors noted issues related to the health care workforce, primarily commenting on strategies to address shortages.
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Mentioned physician and dentist shortage in nearly all of the state’s counties, and outlined plans to increase funding for medical scholarships and loan forgiveness for students committing to serve in underserved areas; also aims to create tax credits for rural providers and increase funding for 12 new residency programs |
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Noted that programs to train individuals in the health care field are expanding |
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Commented on need to address state’s lack of primary care physicians by maintaining funding for physician residency slots and providing medical loan reimbursement; also requests that the Board of Education work with the medical community and higher education institutions to develop plans to address the growing need for healthcare providers |
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Mentioned current state legislation that would permit the state to enter into a compact with other states to allow medical licenses to be interchangeable across states |
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Commented on how plans to expand employment training programs will help address healthcare workforce shortages; a task force will focus on developing innovative solutions to further address these shortages |
Some governors mentioned other specific health topics in their speeches, either as recent accomplishments or as future plans. These included topics such as enhancements to autism coverage, improvements in health coverage eligibility determinations, or lowered prison pharmacy costs.
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Mentioned that state will be providing health care coverage to children of undocumented workers; also state leads the nation in providing Medicaid home-based care, which also gives jobs to health care providers |
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Noted plans to partner with a national nonprofit organization to improve access to contraceptive options by offering better training for health care providers |
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Mentioned that in recognition of the need for private sector resources for Maui’s public hospitals, recently transferred hospital management to Kaiser Permanente |
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Will be forming a working group to address rural health care delivery issues |
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Addressed the water crisis in Flint and proposes support for increasing children’s access to health care and treatment for health issues associated with elevated blood lead levels |
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Highlighted passage of autism legislation to ensure that appropriate services are available through health plans; will expand services at existing autism centers and build a new center |
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Mentioned improvements at state’s Department of Health and Human Services have streamlined low-income residents’ access to nutrition assistance and other assistance programs |
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Mentioned that Department of Correction worked with TennCare to lower prison pharmacy costs annually by $5 million; proposed budget includes funding for a mobile seating and positioning unit in the Department of Intellectual and Developmental Disabilities |
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Noting the importance of helping individuals cope with health and mental health care needs to retain workplace talent, mentioned a recently completed informational kit for employers to provide to employees caring for family members with dementia or Alzheimer’s disease |
Nebraska – Medical Homes
Nebraska Medicaid Patient-Centered Medical Home Pilot
The Nebraska Department of Health and Human Services (DHHS), guided by a governor-appointed physician Medicaid Medical Home Advisory Council, launched a two-year medical home pilot. The program operated under the authority of a 1932(a) state plan amendment, approved by CMS in January 2011. This pilot was limited to two practices selected through a Request for Information process in February 2011; the pilot launched in February 2011 and ran through February 2013.
Nebraska began its process in 2009 with a statutory definition of the medical home and a legislative mandate to implement a pilot. The state then:
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Engaged several key stakeholders;
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Conducted an RFI selection process to determine the practices to participate in the pilot;
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Developed recognition standards;
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Developed the payment structure;
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Developed pilot outcomes and measures; and
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Contracted with TransforMED to provide technical assistance to the pilot practices.
Agendas and meeting minutes for Nebraska’s Medicaid Medical Home Advisory Council are available online here.
It should be noted that Nebraska has implemented managed care in regions of the state that were previously fee-for-service. DHHS requires each Medicaid managed care plan to develop and support at least two practices in becoming medical homes annually.
Multi-Payer Patient-Centered Medical Home Pilot
In January 2014, Nebraska’s major commercial insurers and Medicaid managed care plans voluntarily launched a two-year multi-payer medical home pilot. The pilot aims to align participation requirements and measures across participating payers and practices, and requires payers to contract with an average of ten practices per pilot year. The pilot participation agreement describes expectations for participating payers and practices.
Stakeholders were convened by the Nebraska Legislature, which also supported the planning process. An archive of documents and press information is available online here. Nebraska also received support for this initiative as a member of NASHP’s Multi-Payer Medical Home Learning Collaborative.
Last updated: April 2014
| Forming Partnerships |
Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska Medicaid Medical Home Advisory Council consists of one hospital administrator, six primary care providers (representing family, internal, and pediatric medicine), and one ex-officio legislator, each appointed by the governor. The Council began meeting in October 2009 and continues to meet regularly.
The Nebraska Department of Health and Human Services (DHHS) has also worked to engage a variety other stakeholders, including BlueCross Blue Shield of Nebraska and the Dietetic Association.
The Medical Home Advisory Council is supported by DHHS staff. A job description for the DHHS Medicaid Medical Home Program Coordinator is available here.
Multi-Payer Patient-Centered Medical Home Pilot: Representatives of the following individuals and groups signed the pilot participation agreement:
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| Defining & Recognizing a Medical Home |
Definition:
Nebraska Medicaid Patient-Centered Medical Home Pilot and Multi-Payer Patient-Centered Medical Home Pilot: In Nebraska, a medical home is defined as a health care delivery model in which a patient establishes an ongoing relationship with a physician in a physician-directed team, to provide comprehensive, accessible, and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality, safety, access, and health outcomes in a cost effective manner. For further information, see the Medical Home Pilot Program Act (LB 396).
Recognition:
Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska developed two tiers of recognition. Tier 1 practices were required to meet 29 standards in five “core competencies,” with eight additional standards required to meet Tier 2 recognition standards.
Multi-Payer Patient-Centered Medical Home Pilot: Payers participating in the pilot are not required to use certification or recognition standards. The pilot participation agreement specifies that if participating insurers do require practices be certified or recognized as medical homes, they will accept NCQA PCMH recognition, Joint Commission PCMH certification, URAC achievement, or Nebraska Medicaid PCMH Pilot Program standards.
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| Aligning Reimbursement & Purchasing |
Nebraska Medicaid Patient-Centered Medical Home Pilot: Nebraska developed a unique payment structure to support medical homes through the Nebraska Medicaid Patient-Centered Medical Home Pilot, a two-year pilot which launched in February 2011 and ran through February 2013. Upon signing a participation agreement with the Nebraska Department of Health and Human Services (DHHS), practices were paid $2.00 per member per month (PMPM). This PMPM rate increased to $4.00 upon achievement of Tier 1 recognition. Practices that chose to continue medical home transformation to meet the more advanced Tier 2 standards received 105% of standard rates for select evaluation and management and preventive codes.
Authority for Nebraska’s payment methodology came in January 2011 with the approval of a 1932(a) state plan amendment.
Multi-Payer Patient-Centered Medical Home Pilot: The participation agreement for Nebraska’s multi-payer medical home pilot does not require payers and practices to use a specific payment methodology. Instead, it puts forward broad requirements for payment agreements between participating payers and practices:
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| Supporting Practices |
Nebraska Medicaid Patient-Centered Medical Home Pilot: The Nebraska Department of Health and Human Services (DHHS) provided each practice with:
In addition, the state conducted an orientation and provided two day-long learning collaboratives for physicians, nurses, and key office staff.
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| Measuring Results |
Nebraska Medicaid Patient-Centered Medical Home Pilot: Nebraska identified five outcomes of interest for the Medicaid Patient-Centered Medical Home Pilot, which launched in February 2011 and ran through February 2013:
A list of measures for each outcome of interest is available here.
In addition, TransforMED collected metrics on the progress of the transformation of the practices through the Patient Experience Assessment Tool (PEAT) and provider/staff surveys.
The evaluation for the two-year pilot, competed in November 2013, used analysis of claims data, provider records, and surveys to measure pilot impact on the identified outcomes of interest. Highlights from the evaluation findings include:
Multi-Payer Patient-Centered Medical Home Pilot: The participation agreement for Nebraska’s multi-payer medical home pilot requires participating payers select measures for practice reporting from a mutually agreed-upon list. The lists of adult quality measures and pediatric quality measures are available online.
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Nebraska
In Nebraska
- There were a total of 237,484 beneficiaries enrolled in Nebraska’s Medicaid program as of July 2011. Of these, 202,189 were enrolled in managed care. Of these 100,972 were enrolled in an MCO; 7,282 were enrolled in a PCCM program. Also, 202, 189 received behavioral health services through a specialize managed care program.
- Beginning in July 2012 Nebraska expanded managed care for physical health benefits statewide under its 1915(b) waiver program, Nebraska Health Connection. Dental services are carved out of managed care and are delivered on a fee-for-service basis. In September 2013, the state implemented a full-risk behavioral health managed care program. The state contracts with Magellan of Nebraska to deliver behavioral health benefits.
As of 2013, 196,882 individuals were eligible for Health Check (the Early and Periodic Screening Diagnostic and Treatment benefit, or EPSDT) through Nebraska Medicaid. According to CMS data from 2013, Nebraska achieved an EPSDT screening ratio of 71% and a participation ratio of 46%. 97,888 children received dental services of any kind, with 91,942 receiving preventive dental services.
Last updated May 2014
| Medical Necessity | Regulations in Nebraska establish that:”Nebraska Medical Assistant Program (NMAP) applies the following definition of medical necessity: Health care services and supplies which are medically appropriate and –
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| Initiatives to Improve Access |
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| Reporting & Data Collection |
Managed care contracts specify that “improvement in child/adolescent care” are an objective of the Nebraska Health Connection managed care program and:
“Data for the measures used in this approach are derived from HEDIS and HEDIS-like measures of data collection for performance measures, encounter data, quarterly and annually data reporting required of the contractors, and client satisfaction surveys. Other sources of data may include findings from the External Quality Review (EQR) Technical Report, evaluation results of improvement initiatives, and results from on-site visits.”
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| Behavioral Health |
In September 2013, Nebraska’s Medicaid program implemented a full-risk behavioral health managed care program.
The state’s managed care contract with Magellan lists a number of services covered for Medicaid-enrollees under ago 19, including:
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| Support to Providers and Families |
Support to Families
Nebraska Medicaid offers a Client Information page with information about the program and I has a created a Frequently Asked Questions document on Medicaid managed care for families. The managed care organizations in the state have produced Client Guidebooks with more information about covered benefits, including EPSDT.
Support to Providers
Nebraska Medicaid has also produced a Frequently Asked Questions document on Medicaid managed care for providers. The state makes available an EPSDT “Plan of Care” form to providers; the form establishes medical necessity of services not covered by Medicaid but needed under the EPSDT benefit.
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| Care Coordination |
According to Medicaid managed care contracts,
“Care coordination [under the EPSDT, or Health Check, benefit] must include:
Nebraska has also launched a multi-payer patient-centered medical home pilot in which Medicaid managed care plans are participating.
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| Oral Health |
The state’s Medicaid dental provider handbook contains information on covered services for children, as well as the dental periodicity schedule for children. |
Nebraska
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email skinsler@nashp.org.
Last updated: October 2012
Medicaid Nebraska
Nebraska’s Medicaid HIT targets include: e-eligibility; e-claims expansions; e-prescribing; identification of the Medicaid stakeholder provider community members that qualify for inclusion in HIE and associated EMR/EHR initiatives and incentives; identification of providers who demonstrate increased efficiencies, reduce overuse of services, reduce the duplication of services, and produce improved clinical health outcomes.
As a payer, Medicaid may participate in NeHII and/or Nebraska’s other HIEs.
Medicaid will be required to devise metrics and reporting capabilities that demonstrate value has been obtained from adoption and use of EHR pertaining to reduced prescribing error, reduced duplication of services, and possibly timeliness and accuracy measurement of provider submitted data.
Nebraska
Nebraska’s HIE Strategic Plan puts forth a plan for utilizing existing public-private relationships and regional HIEs to advance health information exchange in the state.
| Nebraska Strategic Plan | 1.1 MB |
