2005-06 State Medicaid Cuts & Expansions: Proposed & Enacted

By Thomas P. McCormack 

Alabama--- Has no spend down;  allows only 12 doctor visits & hospital days yearly and 4 brand name Rx’s monthly (but unlimited generics); but new SCHIP applications are again allowed. The 2007 Medicaid budget will be short $200 million. There’s an ADAP waiting list, and extra emergency federal funding has expired. For more 2003-05 details see http://www.kff.org/medicaid/7314.cfm .The state plans to raise doctor payments.

Alaska---this Title XVI state, with no spend down, froze its Medicaid nursing home eligibility level; cut the CHIP level from 200% to 175% (1,200 families lost children’s coverage); tightened medical qualifications for home personal care for the aged & disabled & created a SPAP to supplement Part D for the limited income aged only—but not the disabled. There’s an ADAP waiting list, and extra  emergency federal funding has expired.

Arizona---has no spend down; while a waiver gives AHCCES (waiver Medicaid) to all uninsured persons under 200% , it unfairly excludes Medicare patients. Even though CMS did agree to let the state impose higher co-pays (e.g., $10 per brand name Rx, $5 per generic, $5 per doctor visit), a court order at least temporarily blocked them.

Arkansas--- Gov. Huckabee (R ) raised $100 million in tobacco & income taxes to prevent elimination of the spend down, Katie Beckett waivers, coverage of eye exams & glasses for adults & to stop nursing home rate cuts. But rates are too low to attract enough dentists & there’s an ADAP waiting list, now that extra emergency federal funding has ended.

California--- new red tape & a reduced income level is taking 200,000 parents off the rolls. The Democratic legislature killed almost all of Gov. Schwarzenegger’s ( R ) proposed cuts. Still, he called for premiums ($4 to $27) for those with incomes over 100% or the SSI level, is forcing the aged & disabled into HMOs (but the legislature postponed 500,000 of such transfers until at least 1/06), proposed a yearly patient dental care cap of $1,000 & got bi-partisan legislative consent to agree with CMS on DSH funding for $3.3 billion more in federal funds over 5 years (but advocates say this is too little & doesn’t provide enough state matching funds). On 12/12/05, the Governor made 5% doctor rate cuts & stopped paying extra Medicare HMO premiums for dual eligibles. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm 

Colorado---has no spend down; a court voided a law to deny benefits to legal aliens & once-blocked CHIP applications are again accepted. A cut of Medicaid Rx’s to 8 a month--except for HIV, cancer & mental cases--fizzled after a physician outcry. Denver’s Medical Center & the University of Colorado Hospital cut their indigents’ care programs & raised their co-pays. Still, an added $2 million in state funds eased the ADAP waiting list. Cigarette taxes voted by referendum will raise the CHIP level from 185% to 200% (enough to cover 4,000 more children), open 600 more HCB and/or Katie Beckett waiver slots to disabled children (but the state is incongruously closing some current HCB cases), raise funding for low income clinics, raise the parents’ income level to 60% (enough to cover 90,000 more), strengthen coverage of the aged & fund the new breast & cervical cancer Medicaid coverage. And while plans for a HIFA waiver were dropped, the state plans to save $59 million by shifting children on Medicaid into HMOs. For more 2003-05 details see http://www.kff.org/medicaid/7314.cfm

Connecticut—a 209(b) state; Governor Rell (R ) vetoed a bill to stop her from seeking a HIFA waiver; raised family Medicaid & CHIP premiums up to between $10 & $75 monthly (an earlier attempt failed); added co-pays of $1 to $3 for doctors; raised Medicaid’s $1 Rx co-pay to $1.50 & $3; upped SPAP premiums from $25 to $30 & its co-pays from $12/$15 to $16.25; imposed a $100,000 SPAP asset test; required recoveries of SPAP costs from estates of the deceased; dropped legal aliens from welfare, Medicaid, CHIP & SAGA (state-funded welfare & medical programs); cut SAGA grants from $350 a month to $200; forced its patients into HMOs; capped its medical budget; established a commission to study Medicaid “reforms”; and ended Medicaid coverage of chiropractic; naturopathy, occupational, physical/ speech therapy & psychology services for adults. But the Democratic legislature raised the parents’ level back up to 150% & repealed the family & CHIP premium increases; Gov. Rell shelved plans to end waiver coverage for 16,000 CHIP parents; and a freedom of information query showed Medicaid HMOs’ specialist rates to be too low to attract sufficient providers.

Delaware---has no spend down; ended its waiver to give Medicaid to childless, non-disabled adults under 100%. The disabled’s SPAP coverage is capped, but the aged get added uncapped drug benefits from a separate, private charity.

District of Columbia---DC’s non-federally-funded Health Alliance covers all uninsured persons under 200% except  Medicare & Medicaid eligibles. DC’s Medicaid levels are 100% for the aged & disabled and 200% for families & children. A 10-year “DC Homes” plan, with $17 million in DC funds, a $25 million federal grant & up to $103 million in private funds, will open 2 & expand 7 primary care low income clinics in poor neighborhoods and a not-yet-implemented DC Rx Access law will offer Rx discounts to non-Medicaid, non-Medicare patients.

Florida---Gov. Bush (R ) began to out-source Medicaid, welfare & food stamp eligibility work to private contractors; and his waiver to privatize Medicaid & convert it, using premium support & health savings account features, into a sort of  managed care insurance was approved by CMS & the legislature (see  Understanding Florida’s Medicaid Waiver Application at www.wphf.org; a waiver pilot plan starts in Jacksonville & Ft. Lauderdale in mid-2006). The state lowered the aged/disabled income level from 88% to the SSI level (over 77,000 will lose coverage 1/1/06) & set up a Medicaid “reform” commission. Florida’s skimpy, aged-only SPAP (which had been transformed into Medicaid Pharmacy Plus waiver) will be abolished January 1, 2006 & a  “fail first” Medicaid drug rule covers costlier mental health drugs only if cheaper drugs first fail to work (but Lamictal, Paxil, Wellbutrin, Lexapro, Zoloft & Zyprexa are exempt). The state restored coverage of adult dentures; again takes CHIP applications anytime instead of only 2 months a year; and a “SUNCAP” program will enroll SSI recipients for food stamps without requiring welfare office visits. Children’s, health , doctor & dentist groups are pressing for legislation—and even filed suit---to raise fees for children’s care & thus increase health access.

Georgia---the state ended spend downs to get nursing home care; lowered the CHIP income level from 235% to 200%; and ended CHIP coverage of vision care, oral surgery & other dental procedures. It cut the Medicaid & WIC level for pregnant women (7,500 lost coverage) & infants from 235% to 185%; raised CHIP premiums from $10 monthly to $35; ended adult coverage for emergency dental care & artificial limbs; is forcing one million patients (including 100,000 aged & disabled, for an estimated $42 million is savings) into HMOs (now delayed until 4/06); dropped adult dental care, orthotics, prosthetics & hospice care; planned time limits on eligibility for patients in the breast/cervical cancer category; set up a Medicaid “reform” commission; capped HCB expenses; and tightened medical eligibility for & added cost-sharing fees to Katie Beckett waiver care. After over 45,000 children lost CHIP, Gov. Pedue (R ) sought a CMS HIFA waiver to cut nursing home access, raise Rx & other co-pays (even for children & nursing home patients) & add more managed care & health savings account features to Medicaid and required applicants (except pregnant women & newborns) to submit papers proving income & citizenship/legal residence. But a state health board voted to ease the 90 day coverage suspensions for children with parents delinquent in paying CHIP premiums. The state’s ADAP may have to adopt some cost-containment measures. In 2005, CMS forbade further use of accounting gimmicks bringing in $300 million yearly in added federal funds; state, CMS & hospital officials began re-negotiating allocation of DSH funds ($419 million in 2004); and rising tax revenues will let the state cut far less than the $269 to $388 million first projected.

Hawaii—a 209(b) state; a waiver gives Medicaid to all the uninsured under 200%, except for aged & disabled, who must be under 100% to get it. State law makes employers offer health coverage to employees & dependents. The state created a SPAP to supplement Part D for aged and disabled patients, but with an income level of only 100%.

Idaho---this Title XVI state, with no spend down, raised the CHIP level from 150% to 185% (but with less benefits & more co-pays than for poorer patients) & funded a pilot health plan for 1,000 adults with new taxes. But it cut funds for a state-county medical program for the temporarily disabled & those awaiting SSA disability decisions and is seeking a waiver to divide the Medicaid/CHIP caseload into 3 classes--healthy parents & children; the disabled & chronically ill; and the aged—and then charge higher premiums & co-pays (even above the federal ceiling) to the first class (but perhaps the others too) and tailor different (possibly more limited) benefit packages for each class. There’s an ADAP waiting list, now that extra emergency federal funding has expired.

Illinois---this 209(b) state’s main SPAP (funded as a Medicaid Pharmacy Plus waiver) excludes the disabled (who get only a limited formulary from a separate Circuit Breaker SPAP); and although a 2005 law authorized making the disabled eligible for the main SPAP’s full formulary, the state still limits the disabled to the old narrow formulary. But the state raised the family income level to 185% (covering 56,000 more adults & children), eased eligibility red tape & passed a hospital tax to fund Medicaid. It then raised income levels even higher to cover 253,000 more children & agreed to a court order raising doctors’, specialists & EPSDT rates for children’s care by $45 million a year to boost access. The legislature voted a $70 million cut in HMO rates & a Lewin study projected 5 year savings of  $1.5 billion if the state forces patients into HMOs, which it will now do to pay for the children’s expansion (HMO enrollment had been voluntary).

Indiana---this 209(b) state’s SPAP still excludes the disabled; and, despite court suits, it still has a much-stricter-than-SSI “209(b)” Medicaid disability rule (one must be fatally or incurably ill). Gov. Daniels (formerly the GOP federal budget-cutting czar) once called for more taxes on the rich to prevent Medicaid cuts, but was then silenced by anti-tax zealots. The state will double CHIP premiums & cut the HCB waiver budget by $14 million in 2006 but will let Medicare patients into its risk pool for secondary coverage (including drugs) at discounted rates & will add 500 more HCB waiver slots (but a KPMG audit found many waiver problems). The state had to take emergency ADAP cost-containment measures and is soliciting bids for a $1 billion contract to privatize food stamp, welfare & Medicaid eligibility, which will close most of the 107 welfare offices now employing 2,500 public workers.

Iowa---the state avoided cutbacks & even got a waiver to offer Medicaid (with premiums up to 5% of income) to up to 30,000 more persons--whether they’re aged, disabled, a parent or not--with incomes under 200% but only at two public hospitals. Yet there’s actually no concrete waiver outpatient drug benefit: Waiver patients who are also previous U. of Iowa hospital “state papers” indigent program  patients are supposedly, but only nominally, grandfathered-in, for one year only & with often-unaffordable co-pays, for its former[limited] free drug formulary; while Polk County [Des Moines-area] residents on the waiver can also access that county’s public hospital free outpatient [limited] formulary; but outpatient drug coverage for other waiver eligibles is sketchy or non-existent. The ADAP waiting list was only partially & temporarily served by now-expired extra emergency federal funding---although $275,000 in state funds were added to the ADAP budget. A state legislative committee began studying ways to cut Medicaid, but Gov. Vilsack proposed a 80-cent hike in the cigarette tax to subsidize health insurance for workers with employers of 25 or less.

Kansas---this Title XVI state’s SPAP will end on January, 1, 2006. Spurning Gov. Sibelius’ (D) call for more health coverage, the GOP legislature passed only token health insurance “reforms”, a limited tax credit to expand small firm health coverage, health savings account measures & a health care re-organization plan. But a new hospital tax will fund higher hospital & physician rates & Blue Cross, with foundation support, will subsidize health insurance for Kansas City-area families earning under $30,000. The state will have to adopt ADAP cost containment measures by March, 2006. A legislative committee studying ways to cut Medicaid has so far called only for more anti-fraud efforts, even though the state must now repay $120 million taken from road funds to avoid health & other cuts during the 2001-03 recession.

Kentucky--- the state had already cut rates for pregnancy & well-baby care, immunizations & health screening at county clinics; hired a PBM & a “disease management” firm for Rx & other savings; and raised Rx co-pays to $1 per generic, $2 per preferred brand name & $3 per non-preferred brand name drug. But it dropped earlier-tightened nursing home & HCB care medical qualification rules; raised the cigarette tax by 30 cents-a-pack (to fund education & Medicaid) with a further 10-cent raise under study; even reinstated 2,500 formerly-dropped mentally ill clients; and passed legislation to create a SPAP to supplement Part D Extra Help for the aged only---but not the disabled---but has failed to implement it. There’s an ADAP waiting list, now that extra emergency federal funding has expired—and there’s $215 million state funds Medicaid shortfall for fiscal 2006. That, and CMS’ decision to ban the use of county hospital, clinic & nursing home budgets as state matching funds, could cost the state $100 million & led it to seek limits of 4-prescriptions-a-month, 15 occupational/physical therapy visits-a-year & 12 x-rays/MRIs-a-year (with appeals allowed), $2 to $10 co-pays for doctor visits, $2 to $20 co-pays for other outpatient care, $10 to $20 co-pays for non-emergency ER visits & a whopping $20 to $50 co-pay per hospital stay (but with annual cost-sharing caps of $225 a person & $350 a family, except for non-Louisville-area patients, who’ll be put into an HMO with a $450 cap; children would face only Rx co-pays; and all preventive care would be co-pay exempt)—and to seek waivers for co-pays of  $3 per generic, $10 for “preferred”  &  $22  for “non-preferred” brand name Rx’s for spend downers.  

Louisiana---the state cut allowed Rx’s from 8 to 5 monthly. An attempt to impose a 200% eligibility level for free care in the State Charity Hospital System died (since its creation by Huey Long in the 1920s, it has accepted anyone unable to pay). In 2005, the state closed 210 mental health & disability centers, ended many Charity Hospital services, cut school health care & adopted a formulary. A new hospital tax-- designed to generate $200 million more in state & federal funds--passed after a $1-a-pack cigarette tax was defeated. The state had to adopt some ADAP cost-containment measures. CMS dropped its claim for a refund of $340 million from past matching funds because of a questionable financing scheme. Hurricanes Katrina & Rita by 10/14 had added 60,000 + cases to Medicaid (with at least as many being denied due to delayed emergency federal funding to expand eligibility); cut state revenues ($1 billion+ for 2005-06 in a legislative study; $1 to $3 billion+ in a federal CBO estimate); left the State Charity Hospital System with no funding after November, 2005; and would have forced Medicaid cuts of  $300 million+ in state funds (and thus $500 million+ in regular federal matching funds) that could have removed over 100,000 children & many others from the rolls and ended Rx coverage for 100,000 more. But while the Budget Reconciliation bill includes $2.1 billion for paying all of LA’s & MS’ Medicaid & uncompensated care costs at a 100% match for as long as that money lasts, final enactment is delayed until Senate-House differences are ironed out after the Christmas break and it is signed into law. That postponement or any further delay will require the state to make immediate Medicaid cuts of at least $200 million.

Maine---the state subsidized health insurance for small employers’ workers & their families; raised the Medicaid income level for the childless aged & disabled to 125% (but stopped taking applications from childless, non-disabled adults under 65) & for parents to 200%; and adopted a formulary (with physician over-rides allowed). After funding shortages threatened coverage of adult dental care; hearing aids & tests, physical, occupational & speech therapy; psychological services; and prosthetics & orthotics, the state raised income taxes on the rich & on tobacco, alcohol, hotels, restaurants, car rentals & soft drinks to fund health care but also appointed a commission to study ways to cut Medicaid expenses.

Maryland---almost all Governor Ehrlich’s (R ) planned health cuts failed in the Democratic legislature, but he did get a ban on new CHIP patients with incomes over 200% and, at least temporarily, CHIP premium raises. He also set up a Medicaid “reform” commission & dropped coverage for legal immigrant children & pregnant women who’ve been here less than 5 years---but the legislature may well reverse this too in early 2006. The state’s lower income band SPAP now excludes Medicare patients, while its higher income band SPAP continues to exclude the disabled and even reduced benefits. While the state did start a high risk health insurance pool, in 11/05 a state insurance regulatory board moved to allow small employer health plans covering 450,000 persons to drop all meaningful prescription coverage.

Massachusetts---after almost all of Gov. Romney’s  (R ) health cuts (except ending almost all MassHealth adult dental care; see http://www.kff.org/medicaid/7378.cfm for details) failed or were reversed by the Democratic legislature, he supported cheap, limited benefit, high cost-sharing policies for the uninsured; more enrollment in Medicaid, a higher minimum wage for firms that don’t offer health plans & a “ CAP” program to give food stamps automatically to SSI recipients; and drafted a plan to give health insurance to 500,000 more persons. But he established a Medicaid “reform” commission; called for tougher work rules even for disabled welfare clients awaiting SSA disability decisions; limited state-funded “Free Care” patients to low income clinics; and imposed $3 clinic & generic drug and $5 ER & brand name drug co-pays on them. The state may be forced to adopt ADAP cost containment by early 2006. In October, 2005, an informal waiver giving the state $585 million extra in federal funds to match state funds from questionable financing schemes was expiring; and threatened to cut $385 million in Medicaid funds if the state doesn’t somehow insure half a million more residents. The House passed a bill imposing 5% to 7% payroll taxes on employers of 10 or more who don’t offer health insurance to raise $176 million yearly to boost the CHIP income level from 200% to 300% & the parental level from 133% to 200%; cover childless, non-disabled adults under 100%; and subsidize health insurance for 200,000 more (the Senate then passed a slightly less liberal bill). When and if a compromise bill is passed by both Houses, Gov. Romney may or may not sign it. He also restored dental coverage for women who are pregnant or have children under age 3. A bill expected to pass and be signed into law by January 1 offers up to 30 days’ of state-financed Medicaid drug coverage for dual eligibles whose transition to Part D is troubled or whose Part D plans don’t cover drugs they need.For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm .

Michigan--- the state, even with raised tobacco & hospital taxes, still had to end almost all Medicaid adult dental, hearing aid, podiatry & chiropractic care. The GOP House majority appointed a task force to study ways to further cut Medicaid. A GOP-passed Senate bill creates $5 monthly premiums for all non-pregnant, non-disabled adults; imposes co-pays of $10 for some brand name drug; charges $2 co-pays for doctor visits, $25 for ER visits & $50 per hospitalization; and raises other Rx co-pays. Gov. Granholm (D) called the bill “unprecedented in [its] cruelty”; but signed a bi-partisan compromise to grandfather-in current recipients; adopt the GOP Senate’s cost-sharing plan; probably impose stricter eligibility rules for new applicants only; or even mandate urine testing for smoking & sugary/fatty diets for non-disabled adults (who’ll then face $10 penalty premiums), but did restore adult dental coverage. The aged-only SPAP will be ended when Medicare Part D drug coverage starts in 2006. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm

Minnesota---this 209(b) state earlier added the disabled to its SPAP, then raised premiums & co-pays for Medicaid, CHIP & MinnesotaCare (state-subsidized health insurance) & cut the latter’s income levels; and denied Medicaid & CHIP  to legal aliens. But GOP plans to abolish the State General Medical Assistance Program (state-only-funded medical care for the childless who are jobless or disabled & awaiting SSA disability decisions) & cut 30,000 from MinnesotaCare failed --and some previously-cut MinnesotaCare medical supplies coverage was restored--after Gov.Pawlenty (R ) and the Democratic Senate agreed to a compromise to end a budget standoff that had closed state offices by enacting a 75-cents-a-pack cigarette “impact fee”. A 2005 court order voided a state law allowing Medicaid providers to deny care or Rx’sto patients who don’t make co-pays, yet the state’s ADAP began dropping patients who don’t or can’t make co-pays.

Mississippi---has no spend down; will lower its Medicaid level for all aged & disabled from 135% down to the SSI level on 1/1/06---causing 65,000 aged & disabled to lose Medicaid—but will then raise it that same day back up to 150% (but only for those aged & disabled on Medicare). The state says it has a waiver to keep using the old, higher aged/disabled level for transplant, dialysis, chemo & mental patients, plus about 7,000 non-Medicare-qualified disabled clients, but lacks funds for 2,000+ HIV patients losing Medicaid. A state committee began studying Medicaid “reform”. Brand name drugs were cut to only  2 monthly (plus 3 generics), but with an informal exception allowing 5 brand name drugs for HIV patients. A lawsuit challenging the drug limits has been filed. A state study estimated state revenue losses from Hurricane Katrina at $213 to $272 million+ just for 2005’s last quarter, but the Budget Reconciliation bill includes $2.1 billion for paying all of MS’ & LA’s Medicaid & uncompensated care costs at a 100% match for as long as that money lasts.

Missouri---this 209(b) state cut the aged/disabled income level from 100% to 85%; ended state medical & welfare programs for the temporarily disabled & those awaiting SSA disability decisions; ended Ticket to Work Medicaid for the working disabled; cut the parents’ income level to 23% from 75% (but a court order will reinstate those parents who can qualify for welfare-to-work Transitional Medical Assistance or as disabled or aged); ended adult dentistry, hearing aid, crutches, wheelchair maintenance, walkers & eyeglasses benefits; enacted new & bigger Medicaid co-pays;  raised CHIP premiums & required 46,000 previously-exempt children to pay premiums (causing nearly half to lose coverage; state officials then rescinded the 6 month penalty waiting period for re-enrollment of those losing CHIP due to premium delinquency); and tightened medical qualifications for nursing home, HCB & home health care. But CHIP co-pays were ended & the SPAP was adapted to supplement Part D for low income patients & expanded to cover the disabled  (but not those in the 2 year waiting period). Blue Cross, with foundation support, will subsidize health insurance for Kansas City-area families earning under $30,000 The state’s ADAP had to adopt some cost-containment measures. A partisanly-divided state Medicaid “reform” committee called for different benefit packages & cost-sharing for families & children, the disabled and the aged; more cost-sharing for almost all patients; but also for restoring the just-dropped coverage of the working disabled (any FICA-taxed work would qualify; countable earnings, after all SSI disregards, must be under 250% FPL; but a very low unearned income [e.g., SSDI] limit would severely limit eligibility). Meanwhile, health advocates started a petition for a referendum to add 80-cents-a-pack more in tobacco taxes to restore Medicaid cuts.

Montana---the state added more & bigger co-pays to Medicaid & CHIP, slashed TANF (welfare) grants, restricted nursing home eligibility, cut doctor visits for the aged & disabled to 10 yearly, dropped coverage of some hospice & home health care & added red tape to cut enrollment--but did find money to end the CHIP waiting list. The state’s “Passport to Health” program saves $20 million yearly by assigning primary care doctors to patients to reduce ER & hospitalization costs. The state is seeking a HIFA waiver to fund a higher CHIP income level to cover 10,000 more children & give watered-down Medicaid  to 3,000 more adults and created a SPAP to pay up to $33.11 in Part D premiums for those aged and disabled Medicare patients under 200% (but won’t pay any deductibles, co-pays or coinsurance or for drugs uncovered by Part D plans, nor  cover those disabled still in the 2 year waiting period). There’s an ADAP waiting list, now that extra emergency federal funding has expired. A state-Blue Cross agreement on financing a $12 million rise in CHIP costs  without higher premiums, a referendum-raised tobacco tax & more state money will fund 2,000 more children on CHIP.

Nebraska----this Title XVI state ended coverage for 15,000 welfare-to-work parents & childless, non-disabled 19 & 20-year-olds. There’s an ADAP waiting list, now that extra emergency federal funding has expired. A state committee suggested Medicaid savings (making it a “defined contribution” plan & promoting assisted living & HCB waivers over nursing home care) of $72 million a year (see http://www.hhs.state.ne.us/med/reform/ ). But, while stopping short of creating a full—fledged SPAP, the state will pay Part D co-pays for those dual eligible Medicare-Medicaid patients in SNFs, ICFs & HCB waiver programs and assisted living, personal care, adult family, board & care & group homes. 

Nevada---this Title XVI state, with no spend down, ended its disregard of unemployment benefits & dropped plans to end the asset test for pregnant women & child-only coverage. Yet it raised $1 billion in new taxes to fund Medicaid; added Ticket to Work coverage for the working disabled;  raised the SPAP’s income level, adapted it to supplement Part D for limited income patients & added SPAP coverage of the disabled (including those in the 2 year wait); planned to use unspent CHIP money (with a waiver) & a CMS risk pool grant to fund health insurance for small employers’ workers & their dependents; added limited adult dental & vision care; added $746,000 to ADAP funding; raised CHIP premiums; rejected adding Medicaid co-pays for Rx’s & other care; and set up a committee to study further Medicaid budget cuts.

New Hampshire---this 209(b) state’s holdover Medicaid Director, often without the Governor’s consent, works with the GOP legislature (which set up a Medicaid “reform” committee) for a HIFA waiver to tighten nursing home eligibility. But Gov. Lynch (D) called for more CHIP enrollment & he added $180,000 more to ADAP. A state law authorized a SPAP to supplement Part D for low income aged and disabled Medicare patients (excluding the disabled in the 2 year wait), but funding plans collapsed; it enacted a 28 cents-a-pack tobacco tax increase to help fund health costs but tied it to road toll & Medicaid changes that could undermine funding; and plans to hire a private firm to ‘coordinate”, and foster cheaper, better care for, the chronically ill & heavy users. It still has a much-stricter-than-SSI “209(b)” Medicaid disability rule (one must be fatally or incurably ill).The state’s ADAP had to adopt some cost-containment measures.

New Jersey---after earlier cuts in the parental income level & dropping legal aliens, the state stopped paying hospital bills  in its non-federal medical program for the temporarily disabled & those awaiting SSA disability decisions. In 2005, it  contracted to privatize eligibility determinations for CHIP, FamilyHealth & Medicaid.. But Acting Governor Codey (D) signed bilIs to simplify eligibility red tape, to gradually raise the parental FamilyHealth income level back up to 133% (enough to cover 80,000 more parents) and to reject proposed co-pays for Rx’s, doctor visits & supervised adult day care.

New Mexico—has no spend down; its Medicaid waiver expansion to uninsured adults under 200% still excludes disabled & aged Medicare eligibles. The state established a Medicaid “reform” commission and plans to—or, as necessary, is seeking waivers to--impose co-pays of $2 per Rx, $5 per office visit, $15 per ER visit & $25 per hospital admission ; to require an “enrollment fee” of $25 & a $10 annual premium; to eliminate rural transport costs to get prescriptions; to end adult eyeglasses & other medical equipment coverage; and to stop non-emergency coverage for illegal aliens. But Gov. Richardson changed eligibility re-certifications to once, rather than twice, a year; boosted outreach; will raise income levels enough to cover 7,800 more children & pregnant women; proposed $7.5 million in tax credits for employers of 10 or less to subsidize health insurance; and added enough state funds to cover one month more of heating bills in LIHEAP.

New York---a “Family Health” waiver covers parents under 150% & childless (even non-disabled) adults under 100% but not childless Medicare patients (who must be under the lower SSI/SSP level for Medicaid). State-subsidized health insurance for workers under 250% excludes part timers & Medicare patients & caps yearly Rx bills at $3,000. The legislature failed to enact a bill to add the disabled to the SPAP; began forcing SSI recipients into HMOs; imposed a 9 month uninsured waiting period for & and forbade public employees from getting, Family Health; raised its co-pays to $5 for doctors & dentists; and to $3 for generic & $6 for brand name Rx’s; ended non-clinic podiatrist coverage; raised other Medicaid Rx co-pays to $1 per generic & $3 for brands; capped yearly Medicaid co-pays at $200; adopted a consumer-friendly formulary; raised nursing home & hospital taxes; is planning cheaper assisted living & adult day care  instead of costlier nursing homes; still seeks a HIFA waiver; and seeks to extend its unique waiver allowing & even funding HMOs, local groups & clinics to enroll & re-certify patients (they’ve added one million to the rolls). The state Counties’ Association has a group studying ways to cut Medicaid & a lawsuit alleges that those moving to new counties must re-apply all over again, in violation of  CMS rules. For more 2003-05 details see http://www.kff.org/medicaid/7314.cfm

North Carolina---in 2003-04 the state cut Medicaid’s income level for pregnant women & infants from 185% to 151% & denied Medicaid to childless, non-disabled 19 & 20 year-olds, but still found $2.765 million more for ADAP. In 2005 the final budget did not lower the aged/disabled income level from 100% to 73%, cut 8,000 others off the rolls or slash home attendant care (as proposed); instead it added coverage of the working disabled & gave $1 million more to ADAP; but cut Rx’s to 5 brand names a month (with unlimited generics). There’s a long ADAP waiting list again (it was only briefly wiped out by extra state & federal funding), the aged-only SPAP ends 1/1/06 & CMS questioned the propriety of $80 million+ in Medicaid HCB & case management services for the severely & developmentally disabled.

North Dakota---this 209(b) state established a Medicaid “reform” commission.

Ohio---this 209(b) state cut the parental income level from 100% to 90% (27,000 lost Medicaid); raised Rx co-pays to the $3 federal maximums; cut the adult dental care budget by 50%, severely reducing access; cut some vision, podiatry & psychologist services;  cut Medicaid secondary payments for dual eligibles also on Medicare; ordered all parents, children & disabled not on Medicare into HMOs; slashed $80 million over 2 years from the non-federal Disability Medical Assistance program for over 15,000 disabled & awaiting SSA determinations; allowed providers to refuse service to patients who don’t meet co-pays (even though it’s against current federal law); but still created over 2,000 new HCB waiver slots and—after ineptly forfeiting $500,000+ in federal funds to plan & run the program-- added coverage of the working disabled. (Ohio’s regular aged/disabled Medicaid level—less than $500 monthly--has long been the nation’s lowest.) In summer, 2005, a state legislative committee began studying ways to further cut Medicaid.

Oklahoma---this 209(b) state cut the Medicaid level from 185% to 100% for children over 1 & from 100% to 73% for the aged & disabled, ended the spend down for families & children, re-imposed a “3-prescriptions-a-month” limit and even cut the nursing home & HCB waiver income level down to the SSI level. In 2005 Gov. Henry (D) added coverage of the breast & cervical cancer eligibility category but GOP House leaders offered $63 million more in state oil revenues to raise hospital rates only if  $100 million in savings from “reforms” (i.e.,cuts) are made. A referendum raised tobacco taxes enough to fund a Medicaid HIFA waiver to subsidize health insurance for over 50,000 small firm employees & their spouses with incomes under 185%; Gov. Henry & the legislature added $5 million in state funds to the $8 million LIHEAP & $2 million low income home weatherization budgets, may add even more & asked energy & church groups for donations too (but consumer advocates say another $6 million is still needed) while a state legislative committee began studying ways to further cut Medicaid and the state’s ADAP had to adopt some cost-containment measures.

Oregon---a Title XVI state; a tax cut referendum caused 70,000+ childless, non-SSI & non-TANF adults to lose coverage through income level cuts & big premium raises & ended spend down eligibility for all but transplant & HIV patients (Oregon Health Plan enrollment fell over 50%). To carry out the legislature’s latest cuts, the state will limit adult dental care; end adult vision & all OTC pharmacy coverage; limit urban non-HMO in-hospital days to 18 yearly; and take more ADAP cost containment steps. Yet the state did enact  mental health/substance abuse parity for private health insurance.

Pennsylvania---budget shortages made the state at least temporarily close enrollments for state-subsidized “AdultBasic” health insurance for adults under 200% (which excludes Medicare patients & has no pharmacy benefit) & the state’s SPAP still fails to cover the disabled under age 65--even though the state will save $100 million every 6 months from the new Medicare Part D drug program. Consumer groups filed suit objecting to state-CMS plans to enroll dual eligibles in pre-selected, individual Part D plans. Gov. Rendell (D) & the GOP legislature agreed to premiums of $40+ monthly plus more & higher co-pays for Katie Becket waiver children in families making over $40,000; and cutting covered inpatient hospital stays to twice a year (but only once yearly for General Assistance patients), inpatient rehabilitation stays to once a year & doctor or clinic visits to 18 a year for adult male patients. But they rejected higher Rx co-pays & monthly numerical Rx limits & Gov. Rendell secured $85 million more from state Blue Cross plans for the AdultBasic insurance budget. The state will be forced to adopt ADAP cost containment measures by 3/06. The state’s Blue Cross plans (which are CHIP contractors) were caught improperly enrolling poor children in their own $50-monthly-premium “Special” plans---which, unlike CHIP, have no dental, vision, hearing or drug coverage—instead of  CHIP.

Rhode Island---the state resisted pressure to close enrollment or cut the 185% parental income level for RIghtCare (a waivered Medicaid/CHIP expansion) & instead added limited coverage of the disabled over 55 to its previously aged-only, limited-formulary SPAP & offered Ticket to Work Medicaid to the working disabled.

South Carolina---has no spend down; a SPAP operated as a Pharmacy Plus Medicaid waiver covers the aged between 100% to 200%--but not the disabled (who must be under 100% to get full Medicaid). The state also raised co-pays for some families on Medicaid & CHIP; cut covered Medicaid Rx’s from 4 to 3 monthly; and added co-pays of  $2 for doctor visits; $3 for dentists; $3 for medical equipment; and $1 for optometrists, chiropractors & podiatrists (its Rx co-pays were already at the $3 ceiling). The state asked for CMS waivers to introduce Medicaid “debit card accounts” (a form of health savings accounts); to set even higher co-pays (e.g., $5 per Rx, $100 per hospitalization. $25 per outpatient surgery); to deny coverage to non-disabled, childless 19- & 20-year olds; and to end EPSDT services at age 18—but then dropped the children’s waiver proposals after a public outcry (there’s still a court suit to block the whole waiver). The SPAP was altered to cover all but a 5% coinsurance of drug costs for Part D patients with incomes under 200% after they reach the donut hole (it also reduces the otherwise-applicable 15% coinsurance to 5% for those with incomes between 135% and 150% after they reach what would—without the Extra Help coverage they enjoy--otherwise be their donut hole) but it still excludes the disabled, on Medicare or not. The state sought, but was denied, a waiver to use federally-matched Medicaid funds to defray Part D Rx co-pays for HCB waiver and residential care facility SSP/Medicaid patients (Part D exempts only those in actual nursing homes or medical facilities from its co-pays).

South Dakota---has no spend down; it planned to set up a high risk health insurance pool & its ADAP had to adopt some cost-containment measures.

Tennessee----the state finally got court approval to end Tenncare (waivered Medicaid) coverage of 191,000+ aged, disabled, parents & “uninsurable” childless, non-disabled adults with incomes over SSI or TANF levels. Children are exempt from cuts & some frail aged & disabled who are “too rich” for SSI or TANF will somehow be “grandfathered-in” for watered-down coverage (with higher premiums, deductibles & co-pays than for those on residual Medicaid). Except for pregnant women, children & HIV+ or physically disabled persons, doctor’s visits are limited to 10 yearly (but only after 6/30/06), hospital days to 45 (again, only after 6/30/06) & Rx’s to 2 brand names plus 3 generics monthly (with no exceptions & co-pays of $3; but without limiting HIV & Hepatitis C drugs). The state adopted a formulary; will set ER co-pays at $5 (or even $5 for some brand name Rx’s if CMS agrees); raise co-pays still more for grandfathered, non-SSI, non-TANF adults ($10/$15 per Rx & up to $40 for doctors!); and end methadone coverage. As token sops, it offered aged/disabled ex-patients temporary Rx discount cards for up to 55 free generics (plus one brand-name anti-psychotic a month for the mentally ill); budgeted (but is only slowly disbursing) $20 million more for low income & county clinics (at least 39 of which, with increased medical staffing, will see any limited income patients for co-pays of only $5, including the dispensing of some outpatient drugs), $5 million for post-transplant care & $3 million for cancer care of ex-Tenncare patients; gave patients with cancer, hemophilia, kidney failure and transplants, even if they lose Tenncare, “safety net” services through 6/06; continued home nursing care until 6/06 and covered Weight Watchers for the obese (with $1 co-pays per session). But it had to take ADAP cost containment measures. Yet with savings from the recent cuts, the state planned again covering up to 100,000 medically needy persons (giving them yearly eligibility); raising income levels for pregnant women & infants; adding hundreds of HCB waiver slots; and widening home health care eligibility & services.  

Texas—In 2003-04 the state dropped its family-only spend down (single aged & disabled never could spend down); ended CHIP coverage of prostheses, physical therapy & private duty nursing; tightened CHIP asset rules; imposed $10 to $20 co-pays for CHIP doctor visits & Rx’s; raised CHIP premiums much more; counted income for CHIP more strictly; imposed a 90 day wait to enroll in CHIP; reduced Medicaid home health care for the aged & disabled; and ended adult chiropractic & podiatry coverage. But a state “personal responsibility” law denying Medicaid to parents who abuse drugs or alcohol or whose children miss school, immunizations or medical or dental checkups was voided by a court. The state established a Medicaid “reform” commission & is seeking a waiver to force TANF children & families in 8 large counties into HMOs that will spend  $109 million less on their care each 2 years, but complex hospital rate issues delayed similar HMO contracts for the aged & disabled. Texas awarded $899 million to a private firm for food stamp, TANF & Medicaid eligibility work, laying off 2,900 state eligibility workers & closing 100 welfare offices. Texas ADAP had to take cost-containment measures, especially for access to Fuzeon; but the legislature restored Medicaid & CHIP mental health, vision & hearing aid coverage & CHIP dental care. In August, 2005, a court found the state in violation of an order for better EPSDT outreach. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm.

Utah---the state’s HIFA waiver gives watered-down Medicaid (no hospital, specialists’, nursing home, home health or other ancillary care; very high drug & other co-pays) to all uninsured adults under 150% --except for disabled & aged Medicare eligibles (who must be under 100% to get full, regular Medicaid). The state also ended Medicaid coverage for adults of podiatry, audiology, speech, occupational & physical therapy, vision & non-emergency dental care for non-disabled adults (but partly & only temporarily restored the dental coverage on10/1/05) and cut chiropractic coverage. The state’s ADAP had to adopt some cost-containment measures.

Vermont—Gov. Douglas’ (R ) proposals—except for a cut in adult dental care-- failed in the Democratic legislature & he vetoed a bill to cover the uninsured. But CMS approved his proposed “HIFA” waiver which, in exchange for about $400 million extra to meet projected 5 year deficits, will force patients into HMOs, promote HCB care over nursing homes & tighten up asset transfer bans-- but also cap future federal funds. The waiver oot final legislative approval in 12/05.

Virginia---a 209(b) state: with $1.3 billion in new sales, tobacco & corporate taxes outgoing Gov.Warner (D) streamlined CHIP; protected the 80%-of-FPL aged/disabled Medicaid level; cut the regressive food sales tax; raised hospital & nursing home rates; funded 700 more HCB waiver slots; increased dental payments & coverage; covered 100,000 more children; and added  $17.9 million (plus $2.7 million from utilities) to the $30 million LIHEAP budget. In spite of Gov.Tim Kaine’s (D) election, the GOP legislature plans to “study” those who conceal excess assets or income; create Medicaid health savings accounts for patients; force more of them into HMOs ; and, of course, increase their cost-sharing. 

Washington---the state reinstated 12 month Medicaid eligibility for children after over 20,000 lost coverage; dropped legal aliens from Medicaid & CHIP (but later reinstated many of the dropped alien CHIP patients, is restoring even more & accepting applications from new ones---although probably only about one-third of the thousands now applying can be covered the first year); cut Basic Health (state-subsidized insurance for those ineligible for Medicare or Medicaid) enrollment from 130,000 to 100,000 & raised its premiums & co-pays; and established a Medicaid “reform” commission. But since added tobacco, gasoline & other taxes to prevent cuts weren’t voted until 2005, 63,000 patients lost Medicaid or CHIP. The state dropped plans for children’s Medicaid premiums; restored limited adult dental care; passed mental health insurance parity; and found $82 million more for mental health & substance abuse services, $24 million more for the homeless; and $100 million more for affordable housing. But with a half-billion dollar budget increase for Medicaid and related programs looming for 2007-09, Gov. Gregoire (D) announced plans to focus on administrative reforms; tighter prescription controls; and targeted case management for chronic, high-cost patients. For more 2003-05 details, see http://www.kff.org/medicaid/7314.cfm .

West Virginia---a raised tobacco tax only briefly put off Medicaid cuts & the state even cut its pitifully-low welfare grants by 25%. State officials called for $3 ER visit co-pays, a monthly limit of 4 brand name drugs & “health investment accounts” that also deter smoking & reward healthy lifestyles. There’s an ADAP waiting list, now that extra emergency federal funding has expired. West Virginia Access-- a new state health insurance risk pool-- began to operate. Yet the state cut medical transport, incontinence, medical equipment & wheelchair supply funding & sought a waiver for a Medicaid “total re-design” & to cut its HCB waiver slots from about 5,000 to under 3,500.

Wisconsin---in spite of big Medicaid budget deficits for 3+ years & continuing financial spats between  Gov. Doyle (D) & the GOP legislature, the state still hasn’t yet made any significant Medicaid, BadgerCare or CHIP cuts (other than small co-pay increases). The state wants CMS to let it force patients into HMOs & got its Medicaid Pharmacy Plus waiver funding the Senior Care SPAP (making it a sort of souped-up Part D/Extra Help plan with a 240% income level) extended to 6/30/07, but failed to add coverage of the disabled. A state legislative committee began to study ways to cut Medicaid.

 Wyoming---has no spend down; the state SPAP (once open to anyone--aged, disabled or not) will now cover only non-Medicare eligibles (but will continue to cover those disabled in the 2 year waiting period) under an income level of only 100%. A state committee began to study ways to cut Medicaid, even though the state’s new Healthy Together program had already saved $15.6 million in preventing un-needed ER visits & hospitalizations, just in the first half of 2005, by assigning care managers (RNs, social workers, etc.) to chronically ill & other Medicaid patients.

For the 48 states & DC, the 2005 federal poverty level (FPL) is $9570 yearly ($798 monthly) for one plus $3260 yearly ($272 monthly) for each additional family member; levels are higher in Alaska & Hawaii (see www.dhhs.gov ).  

States’ August, 2003 cost-sharing, premium & co-pay rules & amounts for Medicaid & SCHIP patients appear in “Medicaid and SCHIP: States’ Premium and Cost Sharing” (03/04) at http://www.GAO.gov/new.items/d04491.pdf  .  But since then, many states have further increased cost-sharing, premiums and/or co-pays.

See www.kff.org/medicaidbenefits for states’ 2003-04 coverage of chiropractors, podiatry, adult dentistry, dentures, orthodonture, eyeglasses, optometry, hearing aids, audiologists, psychologists, prosthetics, medical equipment, hospices, rehabilitation and physical, occupational, speech & other therapy, which many states later cut in 2004-05.

See “Outline on State Medicaid Cutbacks & Responsive Advocacy” at www.healthlaw.org for legal rules states must meet to make cuts & legal arguments to oppose them. Guides & policy arguments for opposing state cuts appear at www.familiesusa.org , www.cbpp.org ,  www.communitycatalyst.org  &  www.TAEP.org .

See “ADAP Watch” at www.NASTAD.org for details on state ADAP waiting lists,  cost containment stopgaps & a list of  state ADAP & Ryan White Program websites, which---with some hunting-- offer detailed state eligibility data. The “National ADAP Monitoring Project 2005 Annual Report: Executive Summary”, Table 1, pp.18-20, at www.kff.org much more conveniently lists all state ADAP income  levels (almost all have asset levels too & where they do, they are  at least as high as Medicaid’s; but they are not listed here), any patient cost-sharing rules & any medical criteria or prior authorization needed  for special or expensive drugs; state ADAP formularies appear in an adjacent document.

See “Waiver Watch” at www.healthlaw.org for news & details on state waivers & proposed waivers.