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Maine Medicaid Waiver Would Increase Patient Responsibility

Maine has applied for a Medicaid waiver from CMS that would require beneficiaries to be employed, pay premiums, and pay fines for unnecessary utilization.

Maine applies for Medicaid waiver

Source: Thinkstock

By Jesse Migneault

- Maine will apply for a Section 1115 Medicaid waiver from the Centers for Medicare and Medicaid Services (CMS) to be granted flexibility to circumvent federal regulations and impose reforms on its Medicaid program.

The state’s proposed changes would increase the level of patient responsibility for Medicaid beneficiaries, and include a work requirement, charges for missed appointments, asset reviews, and a new monthly premium.

“These initiatives are designed to preserve limited financial resources for Maine's neediest individuals, promote financial independence and transitions to employer sponsored or other commercial health insurance, and encourage individual responsibility for one's health and healthcare costs,” said the Maine Department of Health and Human Services (DHHS).

Earlier in 2017, HHS Secretary Tom Price sent a letter to the nation’s governors encouraging them to utilize the waiver option to modify Medicaid and other ACA regulations in their state healthcare systems.

HHS must approve the waiver requests before state officials can put them into effect.

Two changes that are proposed in the waiver are for ‘able-bodied adults’, and would not apply to those with disabilities.  Others are intended for all Medicaid recipients.

If the waiver requests are approved, members who fail to comply will be disenrolled from MaineCare until they achieve full compliance.

Proposed changes for able-bodied adults include:

Work requirements

This proposal is intended to ensure Medicaid recipients aregaining the experience necessary to improve their financial standing and achieve self-sufficiency.”  Members can meet the requirements through a variety of work, volunteer, or other DHHS approved programs.

Payment of Monthly Premiums

Premiums would have to be paid monthly by able bodied adults towards their healthcare coverage.   The state would set up a three-tiered system of premiums based on income brackets.

The following five waiver requests would apply to all MaineCare enrollees.

$20 co-pays for non-emergency or “inappropriate” emergency room use 

In order to decrease costs, this provision seeks to encourage members to receive non-emergency care in other settings.

If members do visit an ER and are not admitted, they will receive a letter from DHHS outlining the cost of their visit for Maine taxpayers.

Charge for missed appointments

Providers would be allowed to bill MaineCare for missed appointments by members.  The waiver provision is attempting to provide an incentive for providers who accept MaineCare members, as well as incentivize those members to keep appointments.

$5,000 asset tests for member households  

This waiver provision would test each MaineCare member’s household Modified Adjusted Gross Income (MAGI).  This test would determine eligibility and ensure that those receiving coverage are paying what they can “in order to preserve MaineCare funding for the neediest members.” 

No retroactive coverage for members

MaineCare would no longer be liable for medical bills incurred by members prior to coverage.  This provision would keep MaineCare more in line with the requirements of private payer insurance.

Hospital presumptive eligibility 

This would eliminate the ability of hospitals to treat patients with an assumption they will receive MaineCare.  The goal is to cut down on taxpayer expenses, while encouraging members to complete MaineCare applications for coverage.

As the nation continues to grapple with the future of ACA Medicaid expansion, and spiraling health costs, the number of state’s applying for waivers is already on the rise. 


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