State Medicaid 1115 Waivers Expand Eligibility, Stabilize Premiums
State Medicaid 1115 waivers are helping to increase Medicaid eligibility, stabilize premiums, and tailor financial policies unique to state healthcare needs.
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By - A number of state governments have submitted Medicaid 1115 waivers to CMS in order to expand Medicaid eligibility requirements, stabilize their in-state premium rates, manage public health issues, and improve behavioral health access.
Currently, 34 states have an approved 1115 waiver in place, while three states are waiting for approval. Fourteen states that already received an approved 1115 waiver are seeking a second or third waiver. Only 14 states and the District of Columbia have not submitted a waiver in any form.
The growth of Medicaid 1115 waiver use followed an announcement from CMS Administrator Seema Verma and former HHS Secretary Tom Price which urged states to submit waivers and defined states as future leaders in managing Medicaid.
1115 waivers allow state governments and their Medicaid agencies to address healthcare issues and financial concerns unique to their citizens. Approved Medicaid waivers have allowed states to adjust Medicaid premium rates, modify health care access, and expand the number of individuals that are eligible for Medicaid coverage.
A breakdown of some currently approved 1115 waivers reveal that many states have used to the waivers to create programs that ensure Medicaid populations have comprehensive healthcare benefits and adequate healthcare access.
A Missouri 1115 waiver aims to improve healthcare access for urban populations
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Missouri has 1115 waiver in place that funds the Gateway to Better Health Program. This program aims to improve healthcare access and affordability for populations in St. Louis. CMS approved the program through the year 2022.
St. Louis city or county residents between the ages of 19 and 64 with annual incomes at or below 100 percent of the federal poverty level (FPL) are eligible to receive primary and specialty care benefits under the program.
Primary care services provided by Gateway to Better Health include preventative dental care, eye exams, and podiatry services. Additional benefits include five urgent care visits per year, limited outpatient services, non-emergency transportation, generic drug prescriptions, and brand name insulin and inhalers.
Eligible individuals participating in the program don’t pay premiums and have co-pays that range from $0.50 to $10.
The Gateway to Better Health Program has provided coverage to 49,000 individuals who would otherwise be uninsured. These individuals have completed 195,000 primary care and dental visits, 800,000 medications to manage chronic conditions and other diseases, and 36,000 specialty care visits so far.
Vermont 1115 waiver aims to improve healthcare access for vulnerable groups statewide
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The Vermont Global Commitment to Health Medicaid 1115 demonstration provides a premium subsidy for individuals who haven’t had insurance for a year or longer. The program covers individuals with incomes at or below 300 percent of the FPL.
Several of the waiver’s components aim to expand healthcare access and choice to individuals with significant financial barriers to receiving care.
Benefits of the program include palliative care and curative care for children with life-limiting illnesses, elimination of $75 inpatient admission co-pays, and full Medicaid State Plan benefits for pregnant women.
Additionally, the Global Commitment to Health Program extends services to cover traumatic brain injuries, long term care services, children’s health, community rehabilitation, and disability services.
The waiver also provides the state with a resource standard of $10,000 for individuals with the highest medical needs. These are individuals who have expected high healthcare costs, who are single, and live in home-based and community settings instead of receiving institutional services.
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The program also allows the state to negotiate prices to providers based on the individual needs of eligible participants. Individuals in the program are able to choose their preferred provider.
The Global Commitment to Health demonstration was extended by CMS through 2021. CMS asked the state to add a substance use disorder amendment to the initial waiver.
New Jersey 1115 waiver demonstration aims to improve affordability for families and individuals
The New Jersey FamilyCare 1115 Demonstration waiver has been extended into 2022 and will add an opioid abuse and substance disorder benefit package along with the traditional benefits for eligible individuals and families.
Individuals between 18 and 65 with household incomes between 25 and 100 percent of the FPL qualify for coverage under FamilyCare. Families of four or more with incomes between 25 and 100 percent of the FPL also qualify. Children in families with incomes up to 355 percent of the FPL ($7,278/month for a family of four) also qualify for coverage.
Eligible individuals under FamilyCare receive coverage for lab tests, imaging tests, prescription drugs, mental health benefits, dental, preventive care, vision, hospitalizations, and primary care visits.
The waiver also includes a premium support plan. Individuals and families covered by FamilyCare pay cost-sharing and premium amounts based on their income totals.
FamilyCare enrollment as of November, 2017 totaled 1.7 million individuals, including 802,111 children, 634,038 adults over the age of 21, and 17,326 young adults under the age of 21.
The state movement towards 1115 waivers may shift Medicaid management into a fully customizable program at the state level based on the increases in waiver approvals and applications over the last year.
