Alabama--has no spend down, an aged/disabled level of $674 (the SSI rate), a parent level of 11%/ 24% if wkg (’11) & an ADAP level of 250%; covers 12 MD visits & hosp days/yr & only 5 brand  Rx’s/mo but has no MSP asset tests. The old legislature (D) cut HIV care $2 million but raised CHIP’s 200% level to 300%. The risk pool once planned low income premium discounts but has no Medicare supplement. There are 2,500 on the HCB waiver waiting list. Gov Bentley (R) & the legislature (both Houses are now R) face a $700 mil-lion Medicaid shortfall; so they started an ADAP waiting list (with 119 on it so far) & cut its formulary. The legislature cut Medicaid’s drug budget by $30 million, but  Bentley res-tored $7 million of that to continue generics coverage with no monthly numerical limit.

Alaska--this Title XVI state has no spend down; an aged/disabled level of $1,036/mo (its SSI/SSP rate), a parent level of 77/81% if wkg (‘11), a 300% ADAP level, a risk pool with a Medicare supplement but no low income premium discount & a token SPAP for those under 175% that excludes the disabled. Flush with big state royalties from high oil prices, Gov. Parnell (R) & the legislature (R House; tied Senate) raised the 175% CHIP level to 200%. While  he refused US grants to plan an Exchange & better police health premium raises, he requested a $160 million budget increase---surprisingly, one-third for Medicaid!

Arizona--covers parents & childless--even non-disabled--adults under 100%/106% wkg. The CHIP level is 200% & ADAP’s is 300%. The legislature (R) killed a program to cover the disabled during the 2 yr Medicare wait, cut MD fees & personal care funds but spared CHIP. With a budget short billions, Gov Brewer (R) cut ADAP’s formulary, mental health funds & home care, ended hospice & non-emergency transport & retained a CHIP freeze that’s cut enrollment by over 10,000 with a waiting list of 40,000. She started new and raised existing co-pays and, with HHS consent, will end the spend down 10/1/11. She ended coverage of physicals, podi-atry, most dentistry, dentures, transplants (she later partly relented), medical equip, insulin pumps, hearing aids, cochlear implants &computerized lower limb prostheses. HHS & CMS, after a brief  last  minute delay and/or indecision, said they couldn’t legally stop expiration of the waiver covering 280,000 childless, non-disabled adults. (Yet coverage of everyone under 100% was mandated by a state voter referendum law & a 2nd referendum amended the state constitution to forbid legislative repeal or not implementing referenda-passed laws; so advocates sued to bar the cut in the state Supreme Ct  & the Maricopa County Ct, but were--at least temporarily--rebuffed by both). Brewer now says she’ll bar new applicants & let coverage of those now eligible lapse by attrition, charge the obese & smokers $50 fees & cut the parent level to 75%

Arkansas—has an aged/disabled level of $674 (the SSI rate), a parent level of 13%/17% wkg (’11), a monthly numerical Rx limit & an insurance subsidy for workers below 200% in small firms. Gov. Beebe & the legislature (both D) covered adult dentistry & passed an unfunded bill to raise the CHIP’s level from 200 to 250%. The risk pool bans Medicare patients once planned low income premium discounts. Beebe may cut the number of covered MD visits & Rx’s; did cut ADAP’s formulary & its income level from 500 to 200% & has a waiting list of 44. He needs $60 million more for the FY 2012 Medicaid budget to maintain eligibility, services & provider fees. So with CMS consent, he’ll begin a gradual, diagnosis-by-diagnosis change of hospital & MD payment systems from fee-for-service to a mixed ACO/DRG-type model 

California-- covers the aged/disabled under 100% (with a $230, not just a $20, disregard), parents below 200% (’11) %. ADAP’s level is 400% & CHIP’s is 250%. With a $19 billion deficit, ex-Gov. Schwarzenegger (R) & the legislature (D) raised premiums; capped child dental care at $1,500-$1,800/yr; cut podiatry & psychiatric benefits; denied non-emergen-cy care to legal aliens & cut provider fees. A $2.75 billion cut dropped 3 million adults. He denied ADAP to county jail inmates. Gov  Brown (D) signed bills cutting “non-life-saving” Rx coverage to 6/mo, MD visits to 7/ yr & MD fees 10%; charging $50 ER, $5 MD & $100- $200 hospital co-pays; and is ending adult day health care (he vetoed a last minute bill to save ½ its funding). A $300 million LA Co Health Dpt. shortfall may cut patients served 1/4 to 1/2. Courts barred ending adult podiatry, chiropractic & dentistry without CMS consent. The state cut funds for home, DD & mental health care & is forcing the aged & disabled into managed care. Brown added $77 million to ADAP, is starting a Health Exchange & add-ing county medical assistance (for childless, non-disabled legal residents under 133% or more in most or all counties) to US-matched Medicaid (see http://www.kff.org/medicaid/8197.cfm  & email adonnelly@projectinform.org for details). But he is also seeking a federal waiver to lower Medicaid costs 10% more with further eligibility cuts barred by the PPACA.

Colorado---has no spend down. The level for those over 60 is $699 (their SSI+ SSP rate), but it’s only $674/mo (the SSI-only rate) for younger disabled. ADAP ‘s level is 400% (but a waiting list may be needed soon). The risk pool has low in-come premium discounts for those below $50,000 & Medicare supplements. Ex-Gov Ritter (D) set up a formulary, made health plans cover PTSD, anorexia, substance abuse & colorectal screening. but cut ADAP’s formulary. Medicaid’s case-load is up 200,00 since ‘01, but he & the old legislature (D) passed a $600 million hospital tax for Medicaid, CHIP & the state indigent health program; to boost hospital rates & uncompensated care funds; and to cover 100,000 more persons by raising all adult levels to 100% (it already covers parents & by 2012 will cover childless, non- disabled adults too) with new US health reform matching; applied the mini-COBRA law to small firms; raised CHIP’s level from 205 to 250%  & widened its psychiatric care; planned to offer Medicaid to the working disabled starting in 7/11, began a SPAP for HIV clients; covered legal aliens; set a 300% level for nursing home & HCB waivers (with liberal HCB & personal aide feat-ures & with some patient autonomy). Advocates for disabled children say the 300% FOA level is too low to cover enough such children; that their Medicaid premiums are too high; and that the state still rations how many cases can be covered. The state lets HMOs sell cheap policies to the uninsured---but cut funds for DD & disabled clients’ employment, transpor-tation and personal aide pay. Gov. Hickenlooper & the Senate (both D), who actually campaigned for more  health expan-sion,  but now plan instead to cut services by $13 million, with likely help from a bare 1-vote new GOP House majority

Connecticut—a 209(b) state with 2-zone aged/disabled levels ($786.22 & $894.61, its SSI/SSP rates for those with over $400/mo shelter costs & a $278 disregard). Its parent level is 185%/191% working {’11); ADAP’s  is 400%; CHIP’s is 300%  and its risk pool has low income premium discounts for those under 200% & a Medicare supplement. It ended SPAP coverage for Medicare patients (but those disabled still in the 2 year Medicare waiting period remain eligible). Ex-Gov Rell (R) ended coverage of legal aliens here under 5 years. There’s no MSP asset test & SPAP income levels are $25,100 for 1; $33,800 for 2). She limited adult chiropractor, naturopath, psychologist  and occu, phys & speech therapy coverage to clinics; but extended hospice care to all Medicaid patients. The legislature (D) covered the wkg disabled. Rell wanted to force patients back into HMOs to fund a skimpy, subsidized “Charter Oak” insurance plan she set up for parents under 306% & other adults under 310%. Its premiums rose 72% since 1/10 & a large premium boost is expected in 9/11; enrollment may even be closed. It has big co-pays, limited psychiatric care, low caps on Rx’s, medical equip & total year-ly costs & a $1 million lifetime cap. CMS provides US matching to give Medicaid to childless, non-disabled adults under 56% who were eligible for state Gen. Med. Asst. (even keeping its $150/mo earnings disregard). The state extended COBRA to 30 mos, and raised QMB’s singles’ income level to $1779.68/mo, SLMB’s to $1,961.28 & QI’s to $2091.67 (thus giving them full Part D Extra Help too).  Gov Malloy (D) proposed, but is re-considering, merging Medicaid & public worker health plans into a “Sustinet” plan that could ultimately expand to universal coverage (but public worker unions oppose it), is moving 2,200 nursing home patients into home or HCB care and will cancel CHIP & Charter Oak managed care contracts He cut respite care; adult dental & vision benefits; and low income clinic funding by $3.8 million

Delaware---has no spend down; covers parents under 100%/120% if wkg & all other adults under 100%/110% if wkg; the ADAP level is 500% and those for CHIP & the SPAP are 200%. Gov. Markell & the legislature (both D) operate a state-funded cancer aid program for those under 650% & state-funded medical assistance (more limited than Medicaid) for others under 200%, covered the wkg disabled, but ended adult vision care and probably speech, phys & occu therapy  

District of Columbia---has parent levels of 200%/207% if wkg, 100% for aged & disabled, 300% for CHIP & 400% for ADAP. DC’s own non-federal medical assistance covers others under 200%/211% if wkg. Ex-Mayor Fenty & the Council (both D) covered adult dentistry; raised the QMB level to 300% & dropped its asset test (thus giving many DC Medicare patients full Pt D Extra Help). But he proposed replacing public mental health clinic care with private contractor services, revoked DC’s just-raised MD fees for dual eligibles & cut home care & funds for disabled clients’ personal aides. DC Me-dicaid now covers even childless, non-disabled legal residents under 65 below 200% with new US health reform matching  

Florida---The legislature (R) got a waiver to move patients (a court order so far lets them opt out) into for-profit manag-ed care; but at first it did so in only 5 counties. Yet it’s still planning to expand the waiver into other counties (starting with the aged & disabled & then adding other patients only later; see http://tinyurl.com/FloridaCHAIN) even though its request to extend & expand the waiver doesn’t yet have final CMS approval. The legislature & Gov Scott (both R) not only want more managed care, they plan to cut MD fees, slash Medicaid costs $1.8 billion, make almost all Medicaid patients pay $10/mo premiums & charge $100 co-pays for non-emergency ER visits. The under-funded, often-closed pre-health reform state risk pool has a Medicare supplement but no low income premium discount. The state cut the aged & disabled level from 88% to SSI’s $674/mo  rate, except for those in HCB waivers or in Medicare’s 2 yr disabled wait-ing period. The parent level is 20%/59% wkg (‘11).. The state covers dentures (but little other adult dentistry) & hearing aids. Ex-Gov Crist (I) dropped Zyprexa & Invesa Sustena from the formulary, made private plans cover autism care, gut-ted the insurance minmum benefits law& fostered cheap policies for the uninsured (see www.coverfloridahealthcare.com; start-up may well be delayed until late 2011 since its policies may not meet US health reform insurance rules without a waiver). Blue Cross & the Dade Co. Health Dept sponsor very cheap, but lean, “Miami-Dade Blue” policies with no brand name Rx benefit. Crist dropped hospice care; cut dialysis, mental health & substance abuse funding & MD fees. There are 19,000 on HCB & home care waiting lists & advocates filed a suit to get more home & HCB spending. Yet a GOP-run legislative budget panel rejected  a $37 million extra US grant to fund more HCB waiver placements over costlier nursing homes. Crist raised cigarette taxes $1 to yield $1 billion (much for Medicaid), vetoed nursing home & DD care fee cuts & made insurers sell Medigap policies almost as fairly to the disabled as to the aged. Miami’s Jackson Mem  Hosp has rising   deficits; is closing 2 O/P clinics & 2 transplant units and ending dialysis for 175 indigents (many are illegal aliens). ADAP cut its formulary & its income level to 200% and has a waiting list of 3,682 (even though 5,403 were shifted to the private Wellvista charity HIV Rx program), to which 1,000 more may be added.  The HIV health insurance premium payment program (with a 400% level) has a waiting list of 260+.  Neither it nor ADAP have asset tests.. Funding shortfalls forced Jacksonville to close 3 low income clinics. Scott made a 15% cut in funds for DD facilities & their staffs 

Georgia---Its aged/disabled level is $674/mo (the SSI rate), its parent level is 28%/50% if wkg (‘11), ADAP’s is 300% & CHIP’s is 235%. It has a monthly Rx numerical cap . It dropped CHIP dental surgery coverage & raised its premiums; ended routine adult dental & artificial limb benefits & nursing home spend downs; and narrowed Katie Beckett waiver ad-mission rules. Ex-Gov Perdue & the legislature (both R) herded patients into HMOs, but allowed opt outs. Atlanta’s Grad-y Hosp, with a $6 million deficit from indigent care costs, closed its dialysis center (but arranged alternate continued care for its many illegal patients) & 3 of its 9 O/P clinics and cut its free care level to 125 from 250%. Perdue wouldn’t raise provider fees & cut ADAP $1.2 million. He failed to get a hospital bed tax (its proceeds were to be used to attract more matching), but MD & DDS fees were still cut; sought more insurance taxes & fines for health costs, closed a mental hosp bldg, cut pregnancy & infant care funds; imposed ADAP medical criteria (its waiting list is 1,716); and  proposed privatiz-ing some mental health care. With a $180 million Medicaid FY 12 shortfall, Gov. Deal (R) proposed even more cuts (i.e., ending adult podiatry, vision & emergency dentistry). but the House voted to retain them. Yet he still wants to raise adult O/P care co- pays to 15%. their I/P hospital co-pays by 400% and even impose cost sharing on children for the first time.  

Hawaii—this 209(b) state gives limited Medicaid waiver care to all adults below 133% (even the childless & non-disab-led, but only parents & the aged & disabled under 100% get full Medicaid. Its ADAP level is 400%. It covers the wkg dis-abled. Ex-Gov. Lingle (R) & the legislature (D) raised CHIP’s level to 300% & ended its premiums. She began moving 37,000 aged & disabled into managed care, ended non-emergency adult dentistry and planned cuts for non-pregnant & non-disabled adults. Gov Abercrombie (D), a liberal once thought to favor health expansion (and who is establishing a voluntary-for-providers Medicaid “medical home model”), still had to cut Medicaid $25 million for FY ‘12 & $50 million for FY ‘13; and limit non-disabled, non-aged adults to 20 MD visits/yr, 10 hospital days/yr  and 3 outpatient surgeries/yr. 

Idaho--is a Title XVI state, with no spend down, an aged/disabled level of $727 (the SSI/SSP rate), a parent level of 21%/ 39% if wkg (‘11) & a 200% ADAP level. The legislature (R) raised the CHIP level from 150 to 185%; funds a pilot plan for small firm workers under 185%, covered the working disabled & sorted clients into 3 groups: Parents & children; disabled & chronic cases; and the aged. Each may get differing benefits or co-pays but more preventive care. Gov. Otter (R) charges 4% of income premiums to Katie Becket cases. And he may charge all disabled children extra premiums; and cut hospital, MD, rehab facility & DD agency fees (which a court voided temporarily) and occupational & speech therapy & autism care funds; and started an ADAP waiting list (it’s now 24). Otter and the legislature plan 2012 Medicaid cuts of $34 million: more & higher co-pays; lower Rx fees; audiology, vision, podiatry & mental health cuts; limiting adult dent-al benefits; moving more patients into managed care; and imposing a $7.5 million  hospital & nursing home “assessment”  

Illinois--this 209(b) state’s aged/disabled level is 100% (with a $25, not just a $20, disregard).Its main SPAP excludes the disabled not yet on Medicare, who get only a limited formulary from a 2^nd SPAP. Both SPAPs’ income levels will be cut from 235% to 200% & their co-pays may be raised, on 9/1/11. The legislature (D) raised the parent level to 185% & ac- cepted a court order to raise pediatric fees. Yet other fees are too low & paid very late, with such a huge unpaid claims backlog that Gov. Quinn {D} may borrow several hundred million dollars; such a loan, with US matching, would fund only a start in paying it down, but still leave Medicaid short $1.2 billion this year). The state earlier raised CHIP’s level 200 to 300%. The often-closed state risk pool has a Medicare supplement but no low income premium discount (yet the new, separate US health reform-funded risk pool’s premiums are affordable for many under age 40 & can be co-ordinated with ADAP and/or Part D). The state raised the wkg disabled level to 350% & required that Medigap policies be sold as fairly to the disabled as to the aged. The U of Chicago Med Ctr closed its women’s & dental clinics & the U of IL at Chic-ago closed a clinic too. The state gave $640 million to safety net hospitals, made hospitals give the uninsured discounts & “assessed” them to attract $450 million more in US matching. With a $13 billion deficit, the legislature gave Quinn power to cut the budget;  raised the 3% state income tax by 2.25%  & boosted other taxes; required better income verification by applicants; is forcing  1/2 of clients (mostly non-disabled parents & children) into “care coordination” in PCCMs & HMOs and 40,000 aged & disabled in Chicago’s suburbs into HMOs. He denied CHIP to children with income over 300%; hopes to save $400 million more with case management for the aged & disabled (38,000 of whom are now on HCB waiting lists); and gave ADAP enough money to serve 4,500 more clients (but with a hard-to-monitor $2,000/mo patient spending cap). Yet a later $1.5 million HIV funding cut means rising ADAP needs can’t  be met, so the income level for new ap-plicants was cut from 500 to 300% on 7/1/11 (grandfathering-in current clients) and the state is starting a waiting list.  

Indiana---this 209(b) state’s SPAP for those under 150% excludes the disabled & has a much-stricter-than-SSI “209(b)” Medicaid disability rule (one must be fatally or incurably ill). The aged/disabled level is $674 (the SSI rate) & the regular Medicaid parent level is 19%/25% wkg (‘11). Gov. Daniels & the legislature (both R) raised CHIP premiums. The  risk pool has a Medicare supplement & a low income premium discount. The ACLU sued to void a once-each-6-yrs denture replacement & re-lining limit (and the legislature is now considering a once-every-5-years eyeglasses replacement limit). ADAP (with a 300% level) may have to start a waiting list & 21,000 DD clients are already on a HCB waiver waiting list, but Daniels did raise the CHIP level from 200 to 300%. A waiver he secured from CMS subsidizes coverage for parents below 200% & even has 42,000 slots for the childless, non-disabled under 65 (with 52,000 more on a waiting list when he closed enrollment). He opposed the US health reform bill, but now seeks to extend the waiver & then use newly-available US health reform matching to cover all non-aged adults under 133% by--or even before--2014 (but only if an HSA requirement s is allowed). Waiver coverage is through HMOs; has few co-pays, but no dental, vision or maternity care. Patients must put 2%-5% of income into HSAs,  pay near-unaffordable premiums and meet $1100/yr in cost-sharing. It has $300,000/yr & $1 million lifetime coverage caps. Daniels plans to cut hospital, nursing home and other provider fees 5%. The State Supreme Court  rejected a suit to make the state consider more possible impairments in Medicaid disability det-erminations Budget cuts will end or limit adult dental, vision, chiropractic & podiatry coverage. Daniels plans to cut the mental health Rx formulary, but druggists got a US judge to temporarily block a cut in the Medicaid Rx dispensing fee. 

Iowa--A waiver covers both O/P & emergency I/P care for non-Medicare adults (even if childless & non-disabled) under 200%/250% if wkg at any Iowa public or low income clinic or hospital. But Rx’s “to go” & elective I/P hospitalizations are offered only at 2 safety net hospitals in Des Moines & Iowa City. The aged/disabled level is $674/mo (the SSI rate), the parent level is 28%/ 83% if working (‘11) & ADAP’s  is 200%. The risk pool has a Medicare supplement but no low income premium discount. Medicaid faces a $600 million shortfall. Ex-Gov. Culver & the old legislature (both D) cover-ed disabled children under 300% via the FOA, raised CHIP’s  level from 200 to 300% & let children with no dental coverage buy into CHIP dental benefits. The hospitals proposed taxing themselves $40 million to attract added US matching funds to raise their rates & meet other rising costs. ADAP program costs were capped on 9/15-- and there’d even briefly been a waiting list. Gov Branstad & the new House (both R) plan to cut Medicaid (such as ending chiropractic coverage, raising co-pays & requiring pre-authorization for more types of care) & a timid state Senate (still D) agreed  to his budget! 

Kansas---this Title XVI state has an aged/disabled level of $674/mo (the SSI rate), a parent level of 26%/32% wkg (‘11), a 200% CHIP level & a 300% ADAP level. Its GOP legislature, covered the wkg disabled, offered state mini-COBRA rights, and raised CHIP’s level to 250%. There are 5,700 on waiting lists for services for phys disabled & DD clients, yet it cut home care fun-ding for the aged & disabled; put 6,000 more on waiting lists for HCB & home care; cut MD fees & disabled clients’ caregivers’ pay, ended welfare for 1,500 awaiting SSA disability awards; denied dental care to poor wo-men; raised CHIP premiums to $20/mo; and froze admissions to state mental hospitals. Ex- Gov. Parkinson (D) sought to have case managers oversee psychiatric Rx therapy and to require more pre-authorizations, charge co-pays for “unneces-sary” ER visits & close state DD facilities to new admissions. Gov. Brownback (R) wants even more health cuts: He ord-ered Aging Dept employee costs slashed 1/4, cut mental health funds $25 million, cut funds for community mental health centers, proposed ending mental health services for 850 families with mentally ill children & told his Lt. Gov. to plan Medicaid cuts of $200 to $400 million yearly by 2013 (by measures such as forcing the aged & disabled into managed care).    .

Kentucky--- has an aged/disabled level of $674/mo (the SSI rate), a parent level of 36%/62% if working (‘11), a 200% CHIP level & a 300% ADAP level. The legislature (R Sen.; D House) dropped tough, unworkable, nursing home & HCB medical admission rules; capped Rx’s at 4/mo, cut home teaching funding for blind children from $80,000 to $10,000/yr, limited occu, phys & speech therapy, x-rays & MRIs; raised co-pays; and divided Medicaid clients into 4 groups who may get different benefits: “healthy” adults; children; aged & disabled; and MR & DD patients. Gov. Beshear (D) faces an im-pendng Medicaid/CHIP shortfall of up to $500 million. He enrolled 22,000 more children in CHIP & dropped its $20/mo premium.  ADAP has co-pays & its formulary was cut. After the Senate (R) got the House (D) to join it to reject his plan to avert cuts by pre-spending $167 million this year of the next biennial budget’s Medicaid funds--and instead fund the current shortfall with cuts to education & other programs---he line-item vetoed their bill & an over-ride attempt failed. Now he is unilaterally implementing his own Medicaid budget plan---centering on the use of  much more managed care. 

Louisiana---has an aged/disabled level of $674/mo (the SSI rate), a parent level of 11%/25% wkg (‘11) & a 300% ADAP level. The legislature (newly R-House; nominally D-Sen) voted to raise the CHIP 250% level to 300% but can’t afford to. Gov Jindal (R) covered the wkg disabled & got CMS to agree to a state refund of only $266 million of past overpayments He found  a $30 million /yr for clinic funding when US funds weren’t renewed & CMS even let him spend $97.3 million in US Medicaid hospital funds on O/P clinics. He wants to save $268 million cutting covered Rx’s from 8 to 5 mo (unless more are “medically justified”); MD & hospital rates and privatizing community services & HCB waiver care for  aged, CMI, DD & phys disabled patients (which a House committee voted against). He still plans to put patients into PPOs & HMOs starting in 2012. US matching fell $700 million in 2011 & 2012’s deficit’s $1.5 billion. Yet he somehow got the US to commit to $400 million more for health care., And FEMA will pay $478 million to rebuild the N. O. Charity Hosp & the state will add $300 million but it must also find $70-$100 million/yr more for hosp operating costs. Jindal wants a $62 million cut for LSU’s Hospitals even though he already lacks enough funds to run 4 to 6 LSU & Charity Hosps as it is. ADAP’s $11.7 million deficit required shifting $2 million of other HIV funds to it, but there’s still a waiting list of 928

Maine—The state, until now,  had these income levels: subsidized insurance, 300% ; the aged & disabled, 100% (with a $75, not just a $20, disregard for both Medicaid & the MSPs); childless, non-disabled adults, 100% (via a Medicaid waiver that had only just started accepting 2,000 new patients); parents, 200%/206% wkg; for regular Medicaid. ADAP, 500%; CHIP, 200%; the SPAP, $1,604/ mo  for 1 & $2,159/ mo for 2; and 250% for an O/P-only waiver care for HIV+ (even “pre-disabled”) patients. There’s no risk pool. Adults get dentures but little other dental care. There are no MSP asset tests and QMB’s income level is 150%, SLMB’s, 170% & QI’s, 185%. The state raised cost-sharing for those over 150%, cut podiatry care & provider fees and  may start an ADAP waiting list .Gov LePage (R) & the new legislature (both Houses are now R) were expected to make big health cuts, yet at first joined Democrats to pay hospitals $70 million in past-due bills (but then a later re-audit of billings showed that, in fact, the hospitals had actually been overpaid  that same amount) & even to add $73 million more to the coming year’s Medicaid budget (for which even more may now be needed because CMS auditors now suspect the state over-claimed $150 million in past US matching). So now LePage plans to drop 16,000-–even though there’s 14,000 more on its waiting list—of the childless, non-disabled  from the waiver (which he claims is a voluntary state add-on & thus needs no HHS approval to be dropped & isn’t subject to the US laws’ maintenance-of-effort rules), and even drop 12,000 parents by cutting their 200% Medicaid income level to 133% 

Maryland---has an aged/disabled level of only $674/mo (the SSI rate), a 300% CHIP level & a 500% ADAP level. An appeals court upheld an AARP/Legal Aid suit to widen the state’s too-strict nursing home, HCB waiver & at-home care medical qualification & appeal rules. A waiver merged the main SPAP & a state low income O/P clinic program into one O/P-only primary clinic care & Rx program for any non-Medicare adults (even if childless & non-disabled) under 116% (128% if wkg). A state-sponsored, Blue Cross-run 2^nd SPAP (with a 300% level) covers some Part D donut hole & premi-um costs, but seems to exclude the disabled. A child’s untreated tooth infection killed him, so Baltimore’s  state dental school & Prince Georges Co. started indigent child dental clinics. The risk pool has low income premium discounts for those under 200%, but no Medicare supplement. Gov O’Malley & the legislature (both D) covered the wkg disabled, raised the parent level to 116% for full Medicaid & subsidize insurance for some low paid small firm workers. He cut $82 million in nursing home, home health aide, private RN & HMO fees & slashed hospital rates to 80% of private plans’. He also plans a 2^nd expansion of full Medicaid to childless, non-disabled adults under 116% with US health reform matching  He again cut providers’, HMOs’, HCB programs’ & the disabled’s personal aide fees & plans to even close a mental hos-pital. He & the nursing homes hope to more than make up their fee cuts with later rate raises funded by a 2% tax they’ll pay to use to attract more US matching. With a $1.2 billion 2012 deficit, he’s considering a $150-$264 million hospital “assessment” to attract more matching to use to raise their rates too & meet other costs. He’s raising child dental fees, carving child dentistry out of HMO contracts to be directly state-run & made hospitals give free care to those under 150% 

Massachusetts---Ex-Gov. Romney (R) & the legislature (D) expanded Medicaid; required everyone to have insurance; subsidized it for those under 300%; boosted the CHIP level from 200 to 400%; raised the parent & childless disabled Medicaid levels to 133% but kept the childless aged level at only 100%. The ADAP level is 488% & the SPAP’s is 188% (but up to 500% for Pt D patients). Gov. Patrick (D), with a $2.5 billion 2012 deficit, raised subsidized insurance, Medi-caid & SPAP cost-sharing; proposed freezing MD & hospital fees; cut funds for substance abuse, tobacco cessation, school RNs & birth control; restricted legal aliens to limited I/P hospital care & a contract PPO network (which some say has too few providers); and proposed confining adult denture & root canal services to community health centers; raising MD & Rx co-pays (even for generics); requiring prior approval of costly psychiatric Rx’s; ending personal aide care for those getting it under 15 hrs/wk; cutting hospital fees & covered I/P hospital days to 20; and requiring college students to be insured. He seeks $331 million in US funds to prop up 7 safety net hospitals; and Cambridge Hosp,, Boston Med Ctr,  St. Elizabeth & Carney hospitals face shortfalls too. The legislature is considering forcing aged dual eligibles into HMOs. To better control costs , Patrick is exploring a gradual shift to Accountable Care Organizations (ACOs) that pay for well-ness & treatment results instead of for the traditional fees-for-services that is said to drive costs above affordability; he al-so ordered a 3% cut in the mental health budget, including $16.4 million for facilities, closing 160 mental hospital beds.  

Michigan---has a 100% aged/disabled level a parent level of 37%/64% wkg (‘11), a 200% CHIP level & a 450% ADAP level. It ended adult hearing aid & chiropractic coverage but has an O/P care-only waiver for childless, non-disabled ad-ults under 35%/45% wkg. The legislature raised co-pays but boosted child wellness, dental & adult preventive fees. The Lansing, Muskegon, Detroit & Flint-area counties offer free or cheap coverage to those under 200% (but F lint’s Genesee Co. had to impose a 2 month waiting period on new applicants & may close enrollment). With a $480 million 2012 defi-cit, the House (once D, but now R) & Senate (still R) briefly ended adult vision care, but then its last budget restored adult dental, vision & podiatry (but not hearing aid or chiropractic) care & avoids MD, hospital & most mental health cuts. Gov Snyder (R) favors preventive care & pledged to--and made--no eligibility or regular provider fee cuts; but did cut teach-ing hospitals $67 million & general Medicaid agency costs $21 million & began forcing dual eligibles into HMOs. The US- funded risk pool cut its premiums ($103 to $415/mo by age band), but to do so had to raise deductibles up to $3,000 & co-pays up to $10, $20, $50 & $100. The state is considering replacing an HMO tax—which CMS now says is improp-er---with a small tax of all claims paid by HMOs and insurers to prevent the loss of $400 million in state Medicaid funds.   

Minnesota---this 209(b) state has an aged/disabled level of 100%, a regular, full Medicaid parent level of 215%/219% if wkg (‘11), a CHIP level of 275%, an ADAP level of 300% & a risk pool with low income premium discounts for those under 200% & a Medicare supplement. With a $5 billion 2012 deficit, ex-Gov. Pawlenty (R) raised premiums & co-pays for Medicaid , CHIP & MinnesotaCare (state-subsidized insurance for parents under 275% & childless, non-disabled ad-ults below 250%) and denied Medicaid & CHIP to legal aliens. He capped enrollment in HCB care and tightened medical qualifications & cut paid hours for home aides; cut nursing home & HCB waiver fees; raised some premiums; and ended coverage of occu & speech therapy, audiology & adult dentistry. Hennepin Co. Med Ctr can’t afford to keep giving free care to other counties’ indigents & had to cut dental, mental health & HIV care. As authorized by the former legislature (D) & the US health reform law, Gov Dayton (D) expanded US-matched Medicaid to cover previously 100% state-funded General Medical Assistance (GMA) patients. Before, 18,000 non-Twin Cities GMA patients had no regular providers at all & even those seen at the 4 Twin Cities hospitals that did take GMA patients had long waits for primary care & longer waits for specialists. Some hospitals & managed care plans considered realizing small budget savings by encouraging the disabled to enroll in managed care & such a bill (allowing opt-outs) passed the new GOP legislature but Dayton vetoed it  After a 20 day standoff & state govt shutdown, he & GOP legislators compromised: He gave up his proposed “million-aire”, added hosp & nursing home taxes and accepted their repeal of provider taxes that had long funded MinnesotaCare. They funded the 100,000+ GMA & MinnesotaCare clients he added to Medicaid, dropped their plan to substitute $240/mo vou chers for them to buy private insurance instead of Medicaid, but they got $400 million in provider fee & other cuts  

Mississippi---has no spend down. Gov. Barbour (R) cut the aged/disabled level from $1,000+ to $724/mo (with a $50, not just a $20, disregard) & there are no MSP asset tests. The parent level is 24%/44% wkg (‘11), CHIP’s is 200% & ADAP’s  is 400% (which may be cut to 200%). Only 2 brand Rx’s/mo & 3 generics/mo are covered (but HIV patients get 5 brand Rx’s). Barbour cut phys, speech & occu therapy benefits. An in-person re-application rule limits enrollment; he & the Senate (now tied) won’t drop it, except maybe for LTC, but the House (nominally D) might. After securing new cigarette & hosp taxes, Barbour proposed DDS, nursing home & hospital (but not MD) fee cuts, as well as patient premiums & big-ger co-pays; proposes a 7% mental health cut, lower mental health center subsidies and closing 4 mental hospitals & 15 mental crisis centers. He won’t use state reserve funds or even enhanced US matching funds to bolster Medicaid (it’s short $34 million). Some disabled children’s parents say the state has tightened Katie Becket waiver medical qualification rules  

Missouri---is a 209(b) state. Its risk pool has no Medicare supplement but has a low income premium discount (and the pool director has called for even more affordable premiums). The GOP legislature cut the aged/disabled level from 100 to 85%; ended medical assistance for those awaiting SSA disability awards; cut the 100% parent level to 19%/ 25% wkg (‘11); en-ded adult dental coverage; raised CHIP premiums; denied CHIP to those whose job plans cost under 5% of  income (with exceptions); raised & more strictly enforced co-pays; but kept the ADAP & CHIP levels at 300% & raised the SPAP level (it covers the aged & disabled if already on Medicare) to 150%. Gov Nixon (D) & the legislature extended the SPAP for 3 years with no changes. Blue Cross & a foundation subsidize insurance for KC-area families under $30,000 The state pays “premium support” for clients’ job plan premiums but denies them full Medicaid for secondary coverage; restored hospice & wkg disabled coverage (but the latter covers only those with very low SSDI checks); gives birth con-trol & screenings to women under 185%; restored adult vision (except  for the aged in nursing homes), hearing aid & pod-iatry benefits; and let the aged & disabled opt out of HMOs .A court made the state widen notice & hearing rights before closing CHIP cases. The state let community health centers & rural clinics presumptively enroll children in Medicaid & CHIP (before, only 4 hospitals could). Nixon asked the legislature to partially restore the parent level (to only 50%), cover all adult dental & vision care & liberalize CHIP premiums & coverage--but it spurned all 3 proposals. Caseload growth made him drop plans to restore the 100% aged/disabled level & boost outreach. He sought cuts of $139 million in hospi-tal rates & $32 million in MD & DDS fees and mental health & public clinic funding; and cut ADAP’s formulary. The state made private plans cover some autism care. CMS said the state wrongly limits home health care to the homebound. 

Montana---has an aged/disabled level of $674/mo (the SSI rate), a parent level of 32%/56% if wkg (‘11), an ADAP level of 330% & a risk pool with low income premium discounts for those under 150% & a Medicare supplement. With a $200+ million deficit, the state raised cost-sharing and cut LTC & hospice benefits and access—and also limited aged & disabled MD visits to 10/yr. But Gov Schweitzer (D) & the legislature (with both Houses now R) ended a CHIP waiting list (yet ADAP has one of 29); seek a waiver to cover more adults; raised the family asset level; set up a SPAP for aged (but not disabled) Medicare patients under 200%; widened CHIP dental & preventive care; and made private plans offer vaccinations & well-child care to age 7. A referendum raised the CHIP level (a 2^nd time) to 250% but the children’s enrollment pace has slowed and Schweitzer appears ready to agree to the GOP legislature’s 6% provider fee reduction. 

Nebraska---is a Title XVI state with a one-house legislature. Its aged/disabled level is 100%, its parent level is 47%/58% if wkg (‘11) & ADAP’s is 200%. It ended Medicaid for many parents who chose to leave welfare to work, yet the state Supreme Ct forbade denying Medicaid to those who fail to meet work mandates. The risk pool has a Medicare supplement but no low income premium discount. Gov.  Heineman (R) covered Pt. D co-pays for HCB & group home clients & raised CHIP’s 185% level to 200%. With a $340 million 2012 deficit, the latest budget cuts non-primary care Medicaid & CHIP reimbursements 5% ($68 million), raised patient co-pays & may limit dental care to $1,000/yr, hearing aids to 1 ea 4 yrs, eyeglasses to 1 ea 2 yrs & adults to 12 chiropractic visits & 60 occu, speech & phys therapy sessions/yr. ADAP’s formulary was cut too. When the state Medicaid program dropped pregnant aliens (even legal ones), over 1,500 untreated cases resulted in needless & costly pre-mature births or still-borns—even though the U of NE Med Ctr offered to cover them in its own indigent program. The legislature is now reconsidering that cut. It did widen school health services. Heineman wants to deny Medicaid to welfare recipients who don’t meet his work requirements. The legislature overrode his veto of the nursing homes’ plan to tax themselves enough to attract more US matching with which to then raise their rates. 

Nevada---a Title XVI state with no spend down; its disabled level is $674/mo (the SSI-only rate), but the aged-only level is $710.40 (their own higher SSI/SSP rate); its parent level is 25%/88% wkg (‘11); its CHIP level is 200%; its ADAP level is 400%. It subsidizes insurance for parents under 200% working in participating small firms & covers the wkg disabled. Its SPAP, with a 225% level, covers the disabled & even offers a vision benefit; but the state raised CHIP premiums. With an $8.5 billion 2011 deficit the state capped CHIP dentistry at $600/yr; ended Medicaid adult dental & vision care, CHIP orthodontia; tightened SNF, ICF, HCB waiver & home care medical eligibility rules; and cut pregnancy coverage, hospital rates (closing the U of NV.at LV Hosp’s dialysis & oncology units) & HCB waiver fees; dropped attendant pay-ments for the disabled; and cut non-emergency transport, and hospital neonatal, HCB waiver & pediatric specialist fees. The LV-area HIV budget was cut $1 million, and many new indigents seeking care at low income clinics are causing them big budget shortfalls. The state set up a formulary for antipsychotic, anticonvulsant & diabetic Rx’s. Gov Sandoval (R) proposed a $200 million cut in the current budget & a $500 million cut in the 2013-14 budget--reducing Rx benefits $104 million (offering no details yet), cutting O/P mental health care $60 million & other provider fees by 15% to 43%. But the legislature’s (still D) relevant committees & the State Supreme Ct rejected $88 million in nursing home, hospital & MD fee cuts and some hospitals & Democrats proposed more & higher business taxes as better alternatives to meet shortfalls. 

New Hampshire---a 209(b) state; its risk pool has no Medicare supplement but has low income premium discounts for those under 250%. Its aged/disabled level is $674 (the SSI rate, with a disregard of  just $13, not $20/mo). The parent level is 39%/49% wkg (‘11); the CHIP & ADAP levels are 300%. It has a much-stricter-than-SSI “209(b)” Medicaid disability rule (inability to work for over 4 years) & doesn’t cover hospices. Gov. Lynch (D) & the legislature (once D, now R) shifted nursing home costs to counties, but ended a DD care waiting list—yet  will make more cuts in hospital, MD, nursing home & mental health fees  They’re forcing most patients into HMOs; cut hospital fees $250 million, slashed $1 million to fund case managers for the aged & disabled in board & care group homes; and even repealed a 20-yr-old hospital tax that had yielded enough funds to attract added US matching to bolster their own & other Medicaid fees. 

New Jersey---has an aged/disabled level of 100%; a 500% ADAP level (but GOP Gov. Christie cut the formulary for cli-ents over 300%; the legislature [D] voted to reverse that, but he will likely veto their bill) & SPAP levels of $31,850 for 1 & $36,791 for 2. A new waiver covers up to 70,000 childless, non-disabled adults with income under $140/mo. The legis-lature raised the parent level to 200% & ended CHIP premiums for those below 200%.  The state cut hospital charity & teaching funds, raised SPAP co-pays and cut its formulary. Christie seeks to drop coverage of legal aliens, township indi-gent care funding & coverage of parents over 133% (but the Wall Street Journal said his proposed lower parent level to be only 25% to 29% FPL). The legislature opposes his $3 adult day-care co-pay proposal and ending state wraparound, Pt D co-pay aid & supplements. He still refuses US birth control, obstetrics and cervical & breast cancer screening funds and vetoed a family planning bill. He plans to meet a $10+ billion deficit by higher cost-sharing; cutting nursing home fees; and seeks a 2^nd “comprehensive” waiver to “save” $300 million (Google “New Jersey Concept Paper” for details) He also plans $240 million in savings by forcing the rest of the aged & disabled (many are still in fee-for-service coverage) into Medicaid managed care plans (including even their Rx, home health, medical day care & personal attendant assistance) and cuts of $8 million each to ADAP & women’s health; $9 million for mental health care---plus $5 million legal aid cut. 

New Mexico—has no spend down, but has a risk pool with a Medicare supplement & low income premium discounts for those under 400%. Its aged/disabled level is only $674/mo (the SSI rate), its parent level is 29%/67% if wkg (‘11), CHIP’s is 235% & ADAP’s is 400%. A waiver—which is again closed to new individual applicants, but not to small employer groups---subsidizes insurance of any adult (even if childless or non-disabled) under 200%/250% if wkg. The state refuses to process disability-based Medicaid-only applications from those whose disability hasn’t yet been approved by SSA---no matter how much they need medical care. With a big Medicaid shortfall (about $300 million+), ex-Gov Richardson & the legislature (both D) dropped expansion plans. The state may have to end adult dental, vision, hearing aid & hospice coverage; slash phys, occu & speech therapy; cut mental health & substance abuse care & fees; and may cut some Rx coverage & HCB waiver care. Gov. Martinez’s (R) expected health cuts are likely to be even deeper, and she hired--without the legislature’s (still D) consent or appropriation---2 consulting firms to advise  how to cut Medicaid’s budget. 

New York---has a waiver for parents & couples (even if childless) under 150%, and childless (even non-disabled) single adults under 65 below 100%---but the level’s only $761/mo for childless aged singles. ADAP’s level is 431% & CHIP’s is 400%. The state subsidizes insurance for workers under 250%, but it caps Rx’s at $3,000/yr. The legislature (D House; R Sen) excludes the disabled from EPIC (NY’s SPAP; it has a 350%+ level); won’t cover digital mammograms; raised Rx & MD co-pays (but caps them at $200/yr);  adopted a flexible formulary; and covers assisted living, chore aide & adult day care. Counties pay ½ of state Medicaid costs (but their increases are capped at 3.5%/yr). NY lets providers deny services to those who don’t meet co-pays; funded HIV day health care; covered colon & prostate cancer patients & the wkg disabled below 250%; required hospital discounts for those under 300% & banned taking debtors’ homes; and required mental health parity. With a $12+ billion 2011-12 deficit, ex-Gov. Paterson (D) made a $1 billion hospital & nursing home fee cut; started a discount Rx plan for the disabled; raised all Medicaid asset levels ($13,050 for 1, $19,200 for 2, etc); ended MSP & SPAP asset tests; extended COBRA to 36 mos; proposed a $65 million group home cut (but then a court ordered 4,300 mentally ill moved into smaller, better facilities) and signed a bill with $775 million in health cuts,  aimed at saving $300 million more in each future year, paring $72 million from low income health programs and making more big hospital fee cuts. Short $316 million, NYC’s  public hospitals plan to cut child mental health & Rx benefits and close some clinics. NYC proposed to end a school dental program & cut its HIV services $17 million and de-funded a health insurance advocacy office, while the safety net St. Vincent Hosp. closed. Mayor Bloomberg proposed to cut 182 school nurse jobs. Gov Cuomo (D) got the legislature to pass $1 to $2.8 billion in Medicaid & EPIC cuts & will force all Medicaid patients into HMOs  A summary of the many, complex cuts is in “Medicaid & EPIC Cutbacks.”at http://www.selfhelp.net/  And a mind-boggling, very detailed set of charts set forth the new income & asset eligibility lev-els and disregards, by family size, for most of  the various health assistance programs at  www.newyorkhealthaccess.org .   

North Carolina---covers the wkg disabled, but allows only 8 Rx’s/mo (plus another 3 or more on an exception basis).Its aged/disabled level is 100%; its parent level is 36%/49% if wkg (‘11) & its CHIP level is 200% .Its aged-only SPAP was suspended in 2010, but may be revived. The legislature (R) created a 2 ^nd SPAP just for ADAP clients on Medicare under 175% but ineligible for Pt D full Extra Help & passed li-mited mental health parity. It has a risk pool that excludes Med-icare patients, requires pre-authorization & has a $250 co-pay for “specialty” Rx’s & a $100,000/yr out-of-pocket cap but does have low income premium discounts.  Gov Perdue (D) seeks $30 million in drug maker rebates with a preferred Rx list (she later added some psychiatric Rx’s to it); proposed closing 50 mental hospital beds & cutting MD, hospital, perso-nal aide, adult dentistry, maternal care & community mental health funds (the last by $210 million). The budget cut audiology; speech, phys & occu therapy; hospice funding; and ADAP (by $3 million), has a formulary limiting coverage to Tier 1 Rx’s & a cut in ADAP’s income level from 300 to 125%). It ends Medicaid’s HIV case manager program & cover-age of community-based rehab care and many child dental X-rays & sealants; limits breast surgery; covers diabetic items at only 1 provider; and requires prior approval of X-rays, MRIs, MRAs, PET scans, ultra-sounds & some EPSDT services.  The state found $14.1 million more for ADAP, cutting its waiting list to “only” 313. The hospitals got the legislature to tax them over $200 million/yr to attract more US matching to raise their rates & meet other Medicaid costs, but it’s considering ending coverage of adult insulin. nicotine gum, eye exams, dentistry, and most podiatry& chiropractic care 

North Dakota---this 209(b) state has a risk pool with a Medicare supplement but no low income premium discount. Its aged/disabled level is $750, its parent level is 34%/59% if wkg (‘11) but ADAP’s level was cut from 400 to 300%. It covered disabled children under only 200% via the FOA, boosted CHIP’s level to 150% & raised the medically needy/spend down level to $750 for 1 person/mo. But the legislature (R) refused to again raise CHIP’s level (to 200%), cut ADAP’s formulary, capped enrollment & yearly costs & limited patient access to Fuzeon. Gov Dalrymple (R) plans even more cuts  

Ohio--this 209(b) state has a parent level of 90% and cut the ADAP level from 500 to 300% (dis-enrolling 257 clients, triggering a waiting list of 238 and possibly denying eligibility to 861 more with CD4 counts over 500 if their CD4 counts haven’t ever fallen below 200). Even ex-Gov. Strickland’s (D) shift of  $12.8 million in new US Medicaid funds to ADAP  did not fully overcome the shortfall. Ohio cut its secondary fees for dual eligibles & medical assistance for those awaiting SSA disability awards; herded most patients into HMOs (some with too few specialists); but required private insurance mental health parity. Its aged/disabled level is still only $589/mo (the US’ very lowest). Strickland  raised CHIP’s level from 200 to 300% ; covered disabled children under 500% via the FOA; got a waiver to cover assisted living; let over-in-come children buy into CHIP; cut nursing home fees (but the legislature then partially restored them & boosted home care benefits); couldn’t afford to cover digital hearing aids; cut Rx fees & community mental health funds; imposed Rx co-pays & a generics preference rule; and delayed MD fee raises--but restored adult dental & vision care. He told nursing homes to pay for their own patients’ phys therapy, wheelchairs & medical equip (which some can’t or won’t cover, so some patients may just do without). He moved 592 from waiting lists into HCB waiver care & imposed $718 million in fees on hospitals to be used to attract more matching & raise rates; and applied  mini-COBRA rights to small firms. Gov. Kasich & the new legislature (both R) plan a $1.4 billion biennial Medicaid cut: forcing disabled children, the mentally ill, nursing home & HCB waiver patients, dual eligibles & eventually all the aged & disabled into managed care; cutting nursing home fees $470 million (but claim they’ll spend $55.6 million more on HCB waiver care, even as they plan very deep cuts in the total FY ’12 LTC budget ); hospital rates $478 million, managed care contracts $58 million & psychiatric care $135 million. He’s giving ADAP only $5 million--but over $22 million more is needed for the 238 on the waiting list.

Oklahoma---this 209(b) state’s aged/disabled level is $716 (the SSI/SSP rate). The parent level is 37% & 53% wkg (‘11) & ADAP’s is 200%. It won’t cover hospices. The state covered the breast & cervical cancer & work-ing disabled groups & subsidized insurance for students, the unemployed & workers under 200% in qualified small firms. The legislature (R) later cut the insurance premiums & eased eligibility but also cut its benefits; co-vers assisted living, raised the CHIP level from 185 to 300%; favors HSAs in employer plans; and gutted the in-surance minimum benefits law Gov. Fallin (R) may drop pregnant women’s dentistry, durable medical equip & nebulizors and cut dialysis, diabetic supply, hospital, MD & nursing home fees;  raised some co-pays; seeks to limit ER visits to 3/yr; cut mental health care; closed 200 mental hospital beds; cut covered brand Rx’s from 3 to 2/mo and ended speech, occu & phys therapy benefits. The hospitals got the House to pass a hospital “assess-ment” to attract more US matching & the Senate voted to use $15 million in unspent ARRA funds on Medicaid.  

Oregon---this Title XVI state’s risk pool has no Medicare supplement but has low income premium discounts for those under 185%. Income levels are $674/mo for aged & disabled (the SSI rate), 32%/40% if wkg for parents (‘11), 185% for insurance subsidies for non-Medicare adults (with enrollment closed) & 200% for ADAP. An anti-tax referendum cut eligibility & adult dentistry and ended adult vision care. The OR Health Plan expansion waiver--with limited Medicaid for non-Medicare adults under 201%--again froze enrollment. ADAP has cost-sharing. Ex-Gov Kitzhaber & the legislature (both then D) took the FOA option & passed insurer & hospital taxes--later upheld in a referendum that raised taxes on the rich too--to cover 80,000 more children & 35,00 more adults, raise CHIP’s level to 300%, & offer more home care--yet he later had to end home care for 100s of cases. Gov Kitzhaber & the Senate (both D) & a now-tied House cut provider fees 16-19%. Both Houses passed & he’ll sign a “coordinated care organizations” bill he says will save $200 million in 2012 

Pennsylvania---has an aged/disabled level of 100%, a parent level of 26%/46% if wkg (‘11) & an ADAP level of 337%. Ex- Gov.Rendell (D) covered the wkg disabled, raised the SPAP level (to $23,500 for 1 & $31,500 for 2, but still excluded the disabled). Gov Corbett (R) & the new legislature (both Houses are now R) want to limit adult dentistry (e.g.,  dropping root canal coverage) & adult Rx’s to 6/mo (with an exception process), impose co-pays on disabled children with family income over 200%, cut mental & women’s health care; and abolished the Adult Basic program--even with 40,000 non-Medicare patients on it & 496,000 on its waiting list) in 2/11. But case record reviews suggest that nearly 1/2 of those dropped may be eligible for Medicaid & they’ve been told so by letter, according to Community Legal Services of Phila.. The 2012 deficit is $4 billion. Phila. city clinics now charge $5-$20 a visit. Rendell priced the premiums as low as $283/mo for those under 200% in PA’s US health reform-funded risk pool, but HHS refused  his plea to waive the US risk pools’ 6 months-with-no-coverage rule even for AdultBasic patients who were dropped and are still uncovered. 

Rhode Island---has these income levels: aged/disabled, 100%, parents, 175% (181% wkg), CHIP, 250% & ADAP 400% (it was cut to 200%, briefly causing a waiting list). The state covers the wkg disabled & its limited formulary SPAP covers the aged but only those disabled over age 55 (with levels of $37,167 for 1 & $42,476 for 2). Ex-Gov Carcieri (R) required free & discount hospital care for those under 200% & 300% and banned taking debtors’ homes. Big deficits ($107 million in 2011) moved him to get a waiver with extra up-front US funds; in exchange it requires shifting 12% of nursing home cases to cheaper home care & caps future US funds. The legislature (D) raised adult daycare co-pays; dropped coverage of legal alien children.& ended childcare workers’ insurance. Gov. Chaffee (I) is expected to have a moderate health policy.

South Carolina---has no spend down. Its aged/disabled level is 100% & its parent levels are 50%/93% if wkg (‘11). It cut its ADAP level to 300%. Its risk pool has a Medicare supplement but no low income premium discount. Ex-Gov Sanford & the legislature (both R) limited Rx’s to 4/mo & raised CHIP’s level to 200%. The SPAP has a 200% level but ex-cudes the disabled. The state cut mental health benefits, closed an HIV program to new clients & slashed home health, hospital & nursing home fees. Yet it passed private plan mental health parity. It also ended SPAP payments for drugs not covered by Pt D, cut SPAP funds & ended state ADAP funding--dropping 200 patients. It may drop 200 more (even with a waiting list already at 858), cut home, personal aide, HCB care (the last 3 face court suits) & covered Rx’s from 8 to 7 mo & de-funded cancer screening.  Gov Haley (R) planned to end hospice coverage (but then relented). She cut speech &occu therapy sessions from 225 to 75/yr. With a $200 million deficit that’s rising to $1 billion, she claims she’ll save  $200 million with” public-private care provider partnerships”; $18.5 million by reducing low birth weight births, boost-ing use of HCB care instead of nursing homes, dropping adult vision & dental care, raising co-pays to the maximums USlaw allows, reducing C-sections & hospital readmissions and $52.5 million in payment cuts to hospitals, MDs & DDSs  

South Dakota---has no spend down. Its aged/disabled level is $674/mo (the SSI rate), its parent level is 52%, wkg or not (‘11) & ADAP’s is 300%. Rejecting a call for expansion, the legislature (R) refused to raise the pregnant women & CHIP levels to 250% or increase provider fees, and ended adult dental coverage.  Gov. Daugaard (R) said he’d make $30 million in Medicaid cuts (with 10% lower provider fees), but the legislature restored $12.5 million to soften the provider fee cuts 

Tennessee—The legislature (R) set the aged/disabled level at $674/mo (the SSI rate), parents’ at 70%/127% if wkg (‘11) & ADAP’s at 300%. Except for the pregnant, children & HIV+ patients, MD visits were cut to 10/yr, hosp days to 20/yr & Rx’s to 2 brand drugs + 3 generics/mo, except for some grave conditions. There’s a 250% CHIP level, a pre-health re-form state risk pool (with no Medicare supplement but with a premium discount for those below 250%), a SPAP (with a waiting list & low benefits cap) for up to 5 generics/mo for non-Medicare clients under 250% & subsidized barebones in-surance for non-Medicare adults under $55,000 (enrollment is closed). CHIP uses Medicaid Rx rules, but also covers dia-betic items & more psychiatric Rx’s. Home care & medical equip benefits were cut, with big mental health cuts & a $500 million hosp rate cut —forcing Nashville Gen Hosp to deny non-emergency care to poor illegals. The state deferred caps on MD visits, transportation & transplant care, but kept a $10,000/yearly benefits cap; limited occu, speech & phys thera-py; and capped X-ray & lab usage & ADAP costs. A court voided its 1987 order grandfathering-in 150,000 ex-SSI recipi-ents to Medicaid & almost all then lost coverage (see “Daniels Case” at www.tnjustice.org). Gov Haslam (R) favors more cuts--like ending coverage of C-sections, hemophilia, detox, acne & some sedatives & may start an ADAP waiting list.  

Texas—has a risk pool with a Medicare supplement & but no low income premium discount .The aged/disabled level is  $674/mo (the SSI rate), the parent level is 12%/26% wkg (‘11) & the ADAP & CHIP levels are 200%. Gov. Perry & the legislature (both R) dropped  CHIP prostheses, phys  therapy & private duty nursing; raised CHIP cost-sharing; cut Medicaid home health & ended adult chiropractic & podiatry care; capped the number of Rx’s covered monthly; moved patients into HMOs; but restored Medicaid mental health, vision & hearing aid coverage and CHIP mental health & dentis-try (Medicaid also covers limited adult dentistry); required some mental health parity in private plans & set up a SPAP for HIV clients. A non-profit (www.TexHealthCoalition.org) fosters subsidized health plans for workers under 300% in small firms in the Waco, Dallas, El Paso, Ft. Worth, Galveston & Houston areas. A court order to improve child health & EPSDT requires higher MD & DDS fees (yet Perry still plans a 10% rate cut). The 2011-12 deficit is $25 billion. The legislature cut the Children with Special Health Needs program--plus a cystic fibrosis aid program for all ages--by $3.5 million (even with 950 children on a waiting list); refused to fund 13,000 needed HCB waiver slots, plus $19 million that ADAP needs & even authorized cutting its level from 200 to 125%  if necessary--even though 15,000 patients already re-ly on it. A Senate-House budget conference committee left $4.8 billion of the Medicaid budget unfunded after early 2013, when the money runs out & the state must either raise more or make huge Medicaid cuts. Ironically, they also authorized transferring $19 million from Medicaid’s already-too-under-funded budget to ADAP’s even more desperate budget needs.   

Utah—is a Title XVI state with a risk pool that has a low income premium discount, but no Medicare supplement. Its aged/disabled level is now 100%, its parent level is 38%/44% if wkg (‘11) & CHIP’s is 200%. A waiver—now closed to new patients--gives limited O/P care, with high co-pays, to non-Medicare adults (even if childless & non-disabled) under 150%. The legislature (R) ended coverage of  podiatry, audiology, speech therapy, chiropractic, outdoor wheelchairs and adult eyeglasses & dentistry (one patient’s untreated tooth infection spread to her brain & killed her); cut hospital & DDS fees 25%; but subsidizes insurance for workers under 150% in small firms. A legislative panel called for gutting the mini-mum benefits law, a ban on pre-existing condition rules & urging employers to offer HSAs instead of regular insurance. The state lets insurers sell even-cheaper-than-COBRA, barebones policies. Gov. Herbert (R) restored dental care for chil-dren & pregnant women and some phys & occu therapy. Yet the state cut DDS fees again (which CMS then disapproved); and cut its ADAP formulary & income level to 250% (dropping 89 clients) & closed enrollment to new applicants--so ag-ain there’s an ADAP waiting list (of 35 so far); cut the disabled level from 100 to 74%, slashed school health funds & the pregnant women’s asset level; and even dropped the spend down. Herbert will (or already has) sign(ed) a bill to force Me-dicaid patients to “work” for their benefits, and he & key legislators are seeking a waiver to operate the Medicaid program with ACOs (which some advocates say are just “gussied-up” HMOs),  raise co-pays and impose $40 monthly premiums.  

Vermont—Its levels are: aged/disabled (2 zones) 101% & 110%; parents, 185%/191% if wkg (’11); childless, non-disabled adults, 150% /160% if wkg; CHIP, 300%; ADAP, 200% & the SPAP, 175%. There are no MSP asset tests. The state subsidizes insurance for others under 300%. Dentures still aren’t covered & there’s a $495/yr dental care cost cap per adult patient. A waiver, in return for more US funds, moves patients into HMOs and favors home & HCB care over nur-sing homes--but also caps future US matching funds. The 2011 health & welfare shortfall was $53 million. Ex-Gov Doug-las (R) promised not to cut eligibility (even signing  a bill requiring more private plan autism coverage), yet raised SPAP co-pays & sought more client cost-sharing (but the Democratic legislature barred CHIP premiums), capped allowed ER visits; and cut provider & Rx fees. Gov Shumlin (D) signed a bill to establish a state single-payer health insurance plan 

Virginia---this 209(b) state’s parent level is 25/31% if wkg (‘11), CHIP’s is 200% & ADAP’s is 400%. It covers the wkg disabled & has a SPAP for HIV+ Pt. D patients under 300%. Gov. McDonnell & the House (both R) ignored gentler Senate (D) proposals to cut provider fees & mental health, substance abuse & community care funds, lower the $2,200/mo HCB waiver income level to $1,685, even with a waiting list of 6,000 (but $30 million more was later found for HCB care); cut CHIP’s level from 200 to 175% (which will turn away 28,000) & the aged/disabled level from 80 to 75%. ADAP’s  formulary was cut, it closed enrollment & dropped 760 patients (except pregnant women, children & those with CD4 counts under 350 or who’ve had opportunistic infections). The waiting list was already 57 & even after the state added $6.2 million more for the biennium, it still rose to 858 (and may rise by 760 more). A bill passed to make big firms’ health plans cover some autism care–-and McDonnell’s line-item veto to cut coverage & employer costs was over-ridden. The state is investigating skyrocketing mental health costs for children & teens by fraudulent & unqualified providers.   

Washington--its risk pool has a supplement open to some, but not all, Medicare patients. Its aged/disabled level is $720 (the SSI/ SSP rate), its parent level is 37%/74% if wkg (‘11) but ADAP’s 300% level was cut to 275%. Gov. Gregoire & the legislature (both D) passed mental health parity. Budget cuts forced her to end CHIP for 27,000 undocumented chil-dren. The state raised BasicHealth (its subsidized insurance for non-Medicare adults under 200%, with a waiting list of 150,000) premiums & co-pays, forcing 60,000 off the rolls; ended medical assistance for 21,000 disabled clients; cut DSH payments & nursing home fees; and limited Rx, DME, imaging, denture, diabetic supplies, personal aide, home care, adult day care, maternity & infant casework & incontinence benefits and cut druggist, pediatric MD, HMO & day health center fees. It dropped adult hearing aids, podiatry, eyeglasses, dentistry, & colorectal cancer screening. ADAP’s formulary was cut & cost-sharing was required, it may have to drop 500 clients & 25% was cut in other HIV care. The state sponsors dis-counted, unsubsidized insurance. A Medicaid waiver pays matching for BasicHealth & “Disability Lifeline”  medical as-sistance, but the state had to cut 17,000 off BasicHealth for being illegals, over  65, or having income over 133%; and the legislature cut Medicaid’s provider rate budget by $4 billion, over opposition by hospitals & home care workers. Gregoire signed a nursing home tax, with proceeds to be used to attract more matching to bolster their rates & other Medicaid costs. 

West Virginia---has an aged/disabled level of $674/mo (the SSI rate), a parent level of 17%/33% if wkg (‘11) & a 250% ADAP level. It covers only 4 brand Rx’s/mo (plus 6 generics). Its risk pool has no Medicare supplement but low income premium discounts have been authorized. It denies all adult dental care but extractions & emergencies & didn’t properly adopt nursing home & HCB medical admission rules (which still impede access). Ex-Gov Manchin & the legislature (both D) started an Rx aid plan for non-Medicare adults under 200%. CMS is trying, over state objections, to halt a waiver that offers clients more mental health care & Rx’s--but only if they sign “personal responsibility” pledges. Manchin raised the CHIP level to 250% but planned to put the disabled, parents & children into managed care that some say cuts care access. Gov Tomblin (D) & the legislature passed a hospital tax with proceeds to be used to attract more US Medicaid matching.    

Wisconsin---has an aged/disabled level of $757.78/mo (the SSI/SSP rate), a 300% ADAP level & a 240% SPAP level  (which excludes the disabled). The risk pool has a Medicare supplement & premium discounts for those under $33,000 Ex-Gov Doyle & the old legislature (both D) raised the CHIP (185 to 300%) & parent (185 to 200%) levels & started a “Basic Care” plan for non-Medicare childless adults under 200%. Its caseload soon far outgrew funding (with a waiting list of 100,000) but Gov Walker & the new legislature (both now R) plan $3 billion in Medicaid cuts, including dropping  the 44,000 already on Basic Care. The new legislature gave Walker sole power (reviewable only by a rubber-stamp, GOP-packed legislative panel) to change Medicaid & other health programs’ eligibility, cost-sharing, benefits and payment laws and policies in order to cut $500 million yearly. He then began dropping those 44.000 adults from Basic Care; and he even intends to freeze enrollment for the aged & disabled and “Family Care” (for parents & maybe also children too) . Yet even GOP legislators themselves rejected his plan to cut SPAP coverage (called “Senior Care” in WI).   

Wyoming--has no spend down, an aged/disabled level of $699 (the SSI/SSP rate), a parent level of 39%/52% if  wkg (‘11) & a 200% CHIP level. Its SPAP covers non-Medicare persons below 100%. The legislature (R) widened CHIP mental health, vision & dental benefits. Ex-Gov Freudenthal (D) added a risk pool low income premium discount for those under 250% (it already had a Medicare supplement) & tried to persuade GOP legislators to start a cheap, subsidized (but very limited) preventive-oriented insurance for working adults under 200% sometime during 2011. FY 2012’s  Med-icaid budget shortfall is $192 million. The state plans to cut provider fees $25 million, the DD & HCB budget $3.6 million (freezing-in a waiting list) & dialysis aid by $250,000. ADAP’s 332% income level & formulary were cut, enrollment was capped (but the waiting list is still only 0) & client cost-sharing was required.  Gov. Mead (R) plans even more health cuts 

SOURCES AND RESOURCES:

Email sherry.barber@ssa.gov for “State Asst. Programs For SSI Recips., 1/10” (the latest update) on state Medicaid eli-gibility rules for SSI & SSP recipients, state SSP amounts and state Sec. 1616, 1634 & 209(b) eligibility arrangements.

 For the 48 states & DC, 2011’s federal poverty level (FPL) is $10,890 yearly ($907.50 monthly) for one plus $3820 yearly  ($318.33 monthly) for each additional person; see the Assistant Secretary for Planning  & Evaluation  pages at www.dhhs.gov  for earlier years’ FPLs and Alaska’s & Hawaii’s separate FPLs. The basic 2011 SSI rates (not includ-ing any state supplements, or SSPs) are the same as in 2009 & 2010:  $674 monthly for 1 and $1,011 monthly for 2.

 For state parent & childless non-disabled adult income levels see “Holding Steady: Looking Ahead.. 50-State Survey of Elig. Rules..[for Parents & Childless Non-Dis Adults]2010-11” [pub.#8132, Tbls B, 4 & 5],“Medicaid..[& MSP] ..Elig..[Levels]  ..for..Elder[s]&..Disab[led] 2009-10 ..”[pub #8048, Tbls 1 & 6] in the Medicaid pages at www.kff.org. and http://www.kff.org/medicaid/upload/8105.pdf  for more detailed 2010-11 aged/disabled eligibility data (App. A4a).

 “Medicaid Expansion Now..[Can]..Save..States Money” at www.kff.org shows how states can add to their health budgets by now getting regular Medicaid  matching rates for 100% state-funded care of childless, non-disabled adults under 133% & “Explaining: Benefits & Cost-Sharing..States Can Set For [New]..[Eligibles]..” (8/9/10) For CMS rules on covering new clients see State Med Dir Ltr #10-005, “New Options.. Under Med..” (4//10/10) & State Med Dir Ltr #10-013 (7/2/10) on required “Fam, Plan. , Benchmark, [mental health & Rx] Coverage” at www.cms.gov

 “Medicaid Coverage & ..[Costs]..in Health Reform..” at www.kff.org projects the numbers of new Medicaid patients & the states’ tiny share of their costs starting in 2014-17 (0% to 10%). See “ The ..States’.. Next Challenge: ..[Getting]..Primary Care to..[More..Medicaid...Patients..]” in the “New England Journal of Medicine” (2/10/11) &

www.unitedhealthgroup.com/reform  about solutions to better deliver rural health care and health reforms & innovations. 

**“The Oregon Health Experiment..”(7/7/11) at www.nber.org finds that, among those actively seeking Medicaid, a study of those who get it vs. those who don’t shows that those who do get it then have much better health & access to care*   

“Net Effects of the [PPACA] on State Budgets”at www.firstfocus.net sees state savings of $40.6 to $131.7 billion/yr  from health reform in 2014-19. The Act & regulations provide a 90% US match to set up & improve Medicaid & Exchange eligibility & enrollment systems and a permanent 75% US match to run them (the old Medicaid match for eligibility, management & claims-payment work was only 50%).  

“The [PPACA] & State[s]; Consider Savings [and] Costs..” (7/13/11) at www.urban.org under “health” in “publications” sees state savings of $92-$129 billion from 2014 to 2019 & $12-$19 billion/yr  afterward  

See “Medicaid’s Role in..Health..Exchanges: A Road Map..” at www.manatthealthsolutions.com   

The ACA “Maximiz[es].. [Primary MD].. Medicaid Rates to Medicare Levels [to get more primary care MDs to take Medicaid patients]..” at www.chcs.org by paying 100% of states’ added fee costs in 2014 – 2019 (and 90% thereafter); and new HHS rules make later state provider pay cuts much harder, cumbersome & time-consuming (Fed. Reg., 5/ 5/11); see “NHeLP Breaks Down Crucial Prov Pay Reg”at www.healthlaw.org 

www.kff.org/medicaidbenefits/ lists state chiropractor, podiatry, eyeglasses, optometry, hearing aid, hospice, psychologist, prosthetics, home health, medical equip, dental, Rx’s, OTC items & phys, occu & speech therapycoverage.

 The “2011 National ADAP Monitoring Report (Module 1)” at www.nastad.org lists state income (and, if applicable, asset) eligibility levels in Table 13, application procedures in Table 14 & any prior authorization rules they have for special or costly drugs in Table 15.  Its “(Module 2)” has a “Glossary” and charts & tables on state ADAP coverage of Hepatitis B & C Rx’s and care (often co-morbid with HIV). State ADAP formularies weren’t compiled in this year’s ”Report” but procedures to get costly or unusual Rx’s are addressed . See the “ADAP Watch” at www.nastad.org  for news on state waiting lists; and current &back issues of the “ADAP Pill Box” at www.ADAPAdvocacyAssociation.org     

See “Pharm. Benefits [in] State [Medicaid]” at www.npcnow.org on formularies, fees, prior auth, prescribing/dispensing limits & co-pays. JCoburn@hdadvocates.org has a chart on how Rx maker PAPs mesh with Pt D. States can cover Pt-D-excluded Rx’s with their own funds: see which do so at www.medicareadvocacy.org (12/1/05 report at “News” icon). “Implementation of Medicare Pt D & Non-Drug Medical Spending..” in jama.ama-assn.org (7/27/11) finds Pt D coverage cuts patients’ other health costs $1,200/yr    

“Medicaid Managed Care Trends” (‘09) on Medicaid’s research &demonstration pages at www.cms.gov says 70%  of Medicaid patients are already enrolled—often mandatorily--in private managed care plans (so far mostly non-disa-bled parents & children); but most states now plan to enroll (again, often mandatorily) the previously mostly-exempt a-ged & disabled too (often even SNF, ICF & board & care home patients, and clients in day, sheltered work & residen-tial programs). See too “CA’s Shift to Managed Care Doesn’t Save [Costs] or Improve.. Outcomes ..”(10/05), find-ing it raises costs 17% over fee-for-services at www.rwjf.org under “publications & research”; a summary of differing cost studies in “Managed Care Explained” (5/31//11) at www.stateline.org, “Assessing.. Financial Health of Medic-aid Managed Care & [Its]..Quality” at www.cmwf.org , “The Evolution of Managed Care in Medicaid” (6/11) at www.macpac.gov/reports . & “Has the Shift to Managed Care [Cut] Medicaid Expenditures?..” at www.nber.org, (it finds that savings depend on the adequacy of  state baseline MD fees). For a good critique of Medicaid HMOs’ fail-ings, quality of care, skimpy provider fees & ways to reform  them, see the 7/27/11 editorial at  www.staradvertiser.com 

See “Hosp. Emerg. Depts: Health Center Strategies That May..Reduce Their..Use” (GAO Rpt. 414R; 4/11/11) at www.GAO.gov     

“Implementing National Health Reform:  A 5-Part Strategy For Reaching the Eligible Uninsured” (5/11), under “publications” at www.ui.urban.org offers thoughtful ways for quick, simple, efficient enrollment by states of the uninsured in 2013-14. Also see “Financial Counselor Qualities” in the “Management Corner” column of CCH’s “Receivables Rpt.” (4/11; Vol. 26, No. 2; paid subscription), “Explaining Health Reform: Uses of Express Lane Strategies ..[for Enrollment in Medicaid & Exchange Ins.]..” at http://www.kff.org/healthreform/8212.cfm. and “New  Lewin/ Optuminsight Whitepaper on the Effects of the ACA on State Medicaid Programs” under” news” at www.lewin.com  

See “Indiv..Models of LTC’ at www.statehealthfacts.org for state coverage of  HCB waivers, home health, personal aides.  Email lsmetanka@nccnhr.org for latest state Personal Needs Allowances (PNAs) for those in SNF, ICFs & licensed, SSI-funded board & care homes. See a “Medicaid HCB..Data Update: 2011” & a “Money Follows the Person Snapshot, 2010” at www.kff.org.  

With no implementing regulations yet, the PPACA’s “Community First Choice” state plan option  can give states a  6%higher matching rate for personal attendant costs & the “Balance Incentives Payment Program” can give them $3 billion ( to raise their match 2% to 5% more)  to plan & arrange such services; email cuello@halthlaw.org for details.   

See www.naschip.org on the pre-health reform state risk pools & order “Compr. Health Ins. for High Risk Indivs: .. State-by-State…” on funding, eligibility, benefits, Medicare supplements, premiums & low income discounts. The site  www.pcip.gov shows if new US health reform-funded  pools are state- or US-run ; the latter’s premiums & cost-sharing are surpri-singly affordable, especially for those under age 40; and premiums in US-run pools were recently further discounted 

See the “Directory of..[the 27]..State Kidney Programs” with contact, eligibility & benefit data under “publications” at http://som.missouri.edu/MOKP/ . FL, MI, NJ & TX health depts. also have epilepsy and/or hemophilia aid programs 

See ”From CANN ” in “Other Organizations’ Materials”  under ”Medicaid” below “Issues” at www.healthlaw.org for a Medicaid, health & welfare “Glossary”, “2011 VA Health ..Benefits”, ”Painless Ways To Deal With State Medi-caid Shortfalls”,  “Ways To Stretch ADAP Budgets” & an archive of many past MEDICAID WATCH issues.  

Email ghbonyman@TNJustice.org for a “Medicaid Maximization Primer” on technical fiscal strategies for states to increase US Medicaid matching for state & local health expenditures and perkins@healthlaw.org for a “Medicaid Cost Containment” Issue Brief on still other techniques to save funds without eligibility, services or provider pay cuts.