Alabama--has no spend down; an aged/disabled level of $674/mo (the SSI rate), a parent level of 11%/ 25% if working (2008) & an ADAP level of 250%; it covers 12 MD visits & hospital days/yr & 4 brand Rx’s/mo; and has an ADAP “enrollment cap”. The deficit is $784 million & Gov. Riley (R) got the legislature (D) to cut CHIP $5 million+ & HIV care $2 million+ but it over-rode his veto of a bill raising the 200% CHIP level to 300%. The risk pool is now adding a low income premium discount but has no Medicare supplement. CMS says the state over-claimed $300 million in the last 4 years, which it wants back

Alaska---this Title XVI state has no spend down, an aged/disabled level of $1,036 (its SSI/SSP rate), a parent level of 80%(2008), 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. Ex-Gov. Palin, Gov. Parnell (both R) & the legislature (R House; tied Senate) raised the CHIP level to 175% & again offer home care A court ordered the state to cover child orthodontia as a required EPSDT service

Arizona--has no spend down or risk pool & covers parents under 200% & childless (even  non-disabled) adults under 100%; its CHIP level is 200% & ADAP’s  is 300%. The GOP  legislature killed ex-Gov. Napolitano’s (D) program to let the disabled buy into Medicaid   during Medicare’s 2 yr wait; cut MD fees & funds for personal care & coverage of  10,000parents. Gov. Brewer (R) faces a $3 billion deficit, cut 200 Rx’s off the ADAP formulary  and may start a waiting list & adopt client co-pays & cost caps; but blocked CHIP cuts.                                                     

Arkansas—has an aged/disabled level of $674 (the SSI rate), a parent level of 14%/17% if working (2008), a numerical Rx limit, but subsidizes insurance for small firm workers below 200%. Gov. Beebe & the legislature (both D) raised DDS fees, covered most adult dentistry, raised low income clinic funding & boosted the CHIP level from 200 to 250%. The risk pool has no low income premium discount or Medicare supplement. Medicaid needs $111 million more in FY10. The state cut the 500% ADAP level to 200%, reduced its formulary & started a waiting list. 

California--The under-funded risk pool (often closed to new patients) has no low income premium discount & bans non-renal Medicare eligibles. Public Citizen says MD fees are the US’ 10^th lowest. The state covers the aged/disabled under $907 or 135%, parents below 100% & prostate cancer patients under 200%. Its ADAP level is 400% & the CHIP level is 250%. With a $26 billion deficit, Gov. Schwarzenegger (R) & the legislature (D) raised families’ premiums & made them re-apply each 6 months; capped dental care at $1,500-$1,800/yr; ended some dental, optometric, podiatry & psychiatric benefits & non-emergency care for legal aliens; cut the parent level to 72%; dropped many 2^nd   ”non-unemployed” parents; cut provider fees; and reduced HIV services $85 million ($12 million for ADAP) & may require Rx co-pays. But he & both parties in the legislature agreed on and then enacted a $196 million insurance tax to continue funding for CHIP. U. of CA leaders proposed a plan to affiliate with & re-open the MLK, Jr. Hosp, which once treated many LA indigents       

Colorado---has no spend down. The old GOP legislature gutted the insurance minimum benefits law & promoted HSAs in private plans, but raised the parent level to 60%/66% if working (2008). The level for anyone over 60 is $699 (the SSI+ SSP rate for them) but only $674/mo (the SSI-only rate) for the younger disabled. The ADAP level is 400%. The Denver Med. Ctr. & the U. of Col. Hosp. cut their indigent care programs and they & the state Indigent program (for the childless poor awaiting SSA disability decisions) and boosted co-pays. The risk pool has a low income premium discount for those under $50,000 & a Medicare supplement. Gov. Ritter (D) adopted a formulary, joined a multi-state Rx buyer pool, made private plans cover PTSD, anorexia, substance abuse & colorectal screening, but proposed de-funding 79 mental health facility beds & cutting state funds for low income clinics by $32.9 million. With a $2.1 billion shortfall, provider fees had already been cut twice; then Ritter called for still more cuts & even delaying payments. Yet he & the legislature (now D) enacted a hospital “fee” to raise $600 million more for Medicaid, CHIP & the state Indigent Care plan to cover 100,000 more persons; applied mini-COBRA rights to small firms, raised the 200% CHIP level to 250% (but only when & if funds are available) & all adult levels to 100%, covered the working disabled under 450%, doubled hospital uncompensated care funding; widened CHIP psychiatric benefits, started a SPAP for HIV patients, covered legal aliens & let HMOs sell cheap barebones policies to the uninsured & unemployed--yet cut DD clients’ employment & transportation funding.

Commonwealth of the Northern Marianas—federal law caps its matching rate far below what states get & it can’t even fully fund its share of Medicaid even though 37% of residents are poor enough for Medicaid. Its low fees attract few MDs & DDSs (only public clinics), but it enrolled some off-island specialists by agreeing to pay Hawaii’s higher Medicaid fees. 

Connecticut—a 209(b) state; its aged/disabled level is about $842 (its SSI/SSP rate), its parent level is 185% (191% if wking) & its ADAP level is 400%; its CHIP level is 300% and its risk pool has a low income premium discount for those under 200% and a Medicare supplement. Ex-Gov. Rowland or Gov. Rell (both R) raised premiums, co-pays & asset levels for the SPAP (its income levels are $25,100 for 1 & $32,900 for 2); ended non-clinic-provided adult chiropractor, naturopath, psychologist and occupational, physical & speech therapy coverage; tightened Medicaid’s “medical necessity” rule; but did extend hospice care to all Medicaid patients. Yet MD & DDS fees are still too low. Rell moved to cut AIDS services by $2.7 million; delay starting an HIV HCB waiver, raise CHIP premiums & co-pays, drop most adult dentistry, end coverage of legal aliens, and cut SPAP coverage. See http://www.cthealthpolicy.org/pdfs/gov_budget_impact.pdf . The legislature (D) covered the working disabled & made private plans let children stay covered to age 26. A freedom of information dispute caused 2 HMOs to drop state contracts. Rell wants to force patients back into contract HMOs to fund her skimpy, state-subsidized insurance plan for those under 300%. It has high co-pays, limited psychiatric care, low Rx & medical equipment yearly cost caps, a $100,000/yr cap on all care & a $1 million lifetime cap. Her veto of a bill authoriz-ing a state “universal” health plan was over-ridden & the state dropped QI’s asset test & raised QMB’s income level to 207%, SLMB’s to 227% & QI’s to 242%--giving most SPAP clients full Pt D Extra Help too. The deficit is $8.7 billion.

Delaware---has no spend down or risk pool; covers all (even childless & non-disabled) adults under 100% & has a 500% ADAP level and 200% CHIP & SPAP levels. Gov. Markell & the legislature (both D) fund a cancer care plan for those under 650% & state medical assistance for others under 200%, raised provider fees & covered the working disabled. The legislature is considering letting over-income children buy into CHIP & cutting Rx fees to meet an $800 million deficit

District of Columbia---has no risk pool. Income levels are 200% for parents, 100% for the childless aged & disabled, 300% for CHIP & 400% for ADAP. DC’s own local, non-federal health program covers others under 200%. Mayor Fenty & the Council (both D) covered adult dentistry; raised dental fees; boosted the aged/disabled asset level by $2,000 & the QMB income level to 300%; dropped the QMB asset test (the last 2 changes thus qualified many DC Medicare patients for Pt D’s full Extra Help too); and passed a law to subsidize insurance for those under 300%. Projected shortfalls of $700 million in the next 3 years required tax increases & program cuts. Accounting problems are delaying DC’s quest for $176 million in US matching for still-un-submitted 2003-09 Medicaid claims. It had to postpone plans for provider fee raises & implementing its law authorizing more liberal subsidized insurance; spent $51 million to subsidize & expand low income primary care; but is replacing its public detox facility & public mental health clinic care with private contractors’ services. The Washington Post is running a series on how millions have been wasted on fraud & ineptitude in DC’s HIV program.

Florida---Ex-Gov. Bush & the legislature (both R) got a waiver to privatize Medicaid, using premium support & HMOs, but a court let patients leave HMOs for “good cause”. The under-funded risk pool—long closed to new patients---has a Medicare supplement but no low income premium discount. The state cut the aged/disabled level from 88% to the $674/mo SSI rate, but grandfathered-in those under 88% who are in HCB care or not (yet) on Medicare. The parent level is 21%/55% if working (2008) & ADAP’s is 300%. The state covers dentures (but little other adult dentistry) & hearing aids. Gov. Crist (R) started an Rx discount plan; cut HMO fees; dropped Zyprexa from the formulary; and proposed letting children over the 200% CHIP level buy in at cost. He also signed bills to make private plans cover autism care; let children stay covered in private plans until age 30; gut the insurance minimum benefits law; sponsor cheap, barebones policies for the uninsured (see www.coverfloridahealthcare.com & ask BC/BS & local health depts. about the subsidized “Miami-Dade Blue” plans with discount premiums & low co-pays, but no brand name Rx coverage); drop hospice & cut dialysis care; cut mental health & substance abuse funds & MD fees; put more patients in HMOs; and, with a $2.6 billion  Medicaid shortfall in 2009-11, cut Medicaid $803 million. See www.floridachain.org  & www.hpi.georgetown.edu/florida and “FL Medicaid Waiver ..” at www.kff.org & “New ..FL. Health Plans” at www.cbpp.org  Home care & HCB care waiting lists are long, but the state settled a suit that consumer groups filed by agreeing to spend $27 million to expand HCB waiver care as an alternative to nursing homes. Crist restored $22 million for care of the aged & disabled, medical care for 900 special needs children and mental health & substance abuse care; and signed bills easing CHIP red tape & raising cigarette taxes $1 to yield $1 billion for Medicaid & other priorities. The legislature (still R) required that Medigap policies be sold as fairly to the disabled as to the aged; considered covering the working disabled; and only just realized that overlooked clauses in the CMS waiver require big coverage expansions by 2011 to avoid losing $300 million in US funds. Miami’s Jackson Mem. Hosp’s 2009 shortfall is $168 million, so it’s closing 2 O/P care clinics & 2 transplant units    

Georgia---has no risk pool. Its aged/disabled level is only $674/mo (the SSI rate), its parent level is 29%/52% if working (2008), ADAP’s is 300% & CHIP’s is 235%. It has a monthly numerical limit on Rx’s; ended dental surgery coverage in CHIP & raised its premiums; ended coverage of adult emergency dentistry & artificial limbs and nursing home spend downs; and tightened Katie Beckett waiver admission rules. Gov. Perdue & the legislature (both R) herded patients into HMOs (but permit opt outs) but ended suspensions for late CHIP premiums Added red tape cut child enrollment 100,000 & provider fees are too low. Atlanta’s Grady Hosp. & Savannah’s Mem. Health Univ. Hosp. are short many millions due to indigent care costs. Grady also faces being dropped as a provider for a Medicaid insurance contractor covering 12,000 of its patients; must re-pay $20 million in past Medicaid overpayments; and has a current shortfall of $36 million---requiring closing its dialysis clinic & 3 of its 9 O/P clinics and cutting its free indigent care level from 250 to 125%, with partial discounts for those under 200%. Facing a $2.6 billion deficit. Perdue dropped planned HMO, hospital & provider fee raises; was considering a $1.2 million ADAP cut; called for a $186 million hospital rate cut, proposed new taxes & fines to meet CHIP, Medicaid & hospital trauma costs & is considering privatizing much of public mental health care; but signed a bill subsidizing insurance for low wage small firm workers. (Discounted but still-high premiums will buy only  “basic”, high deductible policies requiring HSA deposits;. see “New GA ..Health Plans..” at www.cbpp.org.) GOP legislators are considering at least partial repeal of the mandated minimum benefits law for private health insurance; and Macon Co.’s $3 million cut in funding for the Med. Ctr of Central GA will reduce clinic hours, services & Rx benefits

Guam—this territory’s matching funds are capped by law far below what states get. Its local medically indigent program (MIP) pays even less than Medicaid & has almost no private providers. Scanty funding for off-island specialty care & air transport to it runs out quickly. Provider fees are too low & paid too late. Only 1 dentist takes Medicaid & CHIP patients

Hawaii—a 209(b) state with no risk pool. It covers parents & other (even childless & non-disabled) non-Medicare adults below 200%. But the aged/disabled level is only 100%, while ADAP’s  is 400%. The state covered the working disabled & has a token SPAP for Medicare patients under 100%. Gov. Lingle (R) & the legislature (D) raised the CHIP (to 300%) & parent (to 250%) levels; restored some adult dentistry; ended CHIP premiums but, facing a deficit, dropped premium-free CHIP for over-income children. Lingle called for ending “free Medicaid” (whatever that may mean) for some low income adults; the legislature dropped plans to raise MD fees to the Medicare rate; and an ADAP waiting list may be needed. US Courts are hearing 3 suits to block state plans to herd 37,000 aged & disabled into for-profit, sub-par HMOs.

Idaho---a Title XVI state, with no spend down; an aged/disabled level of about $727 (the SSI/SSP rate), a parent level of 22%/28% if working (2008); an ADAP level of 200%; and a risk pool with no Medicare supplement or low income premium discount. The GOP legislature raised the CHIP level from 150% to 185%; funds an under-used pilot plan for poor (even childless & non-disabled) adults & small firm workers; covered the working disabled; and got CMS to allow 3 patient groups: Parents & children; the disabled & chronic cases; and the aged---who may get differing benefits or more co-pays but also more preventive care. Gov. Otter (R) covered adult dentistry, but a projected Medicaid shortfall of $387 million forced him to charge premiums of 4% of income to Katie Becket cases, and cut hospital & rehab facility fees 55% (which a court then barred), plus occup. & speech therapy; mental health & “partial care” funding. The deficit may require an ADAP waiting list. He & the legislature may cut nursing home & provider fees and drop non-emergency transportation  

Illinois---this 209(b) state’s aged/disabled level is 100% but its main SPAP originally excluded the disabled, who got only a limited formulary from a 2^nd,SPAP (both had 200% levels). Ex-Gov. Blagjoevich & the legislature (both D) first added HIV drugs to the 2^nd SPAP’s formulary (but only for Medicare patients). Then a law was passed--over Gov. Quinn’s (D) veto-- to let the disabled (but again, only those on Medicare) enroll in the main SPAP & get help with out-of-pocket costs for Rx’s their Part D plans cover---starting 1/1/10, with the SPAP levels raised to $27,60 for 1, $36,635 for 2 & $45,667 for 3; and with later annual COLAs authorized. The state raised the parent level to 185%, fixed the ADAP level at 400%, accepted a court order to raise pediatric fees (yet other state fees are too low & paid very late, and there’s still a gigantic claims backlog), offered subsidized insurance to veterans left uncovered by VA cuts and raised the CHIP level from 200 to 300%. The under-funded risk pool, often closed to new patients, has a Medicare supplement but no low income premium discount. Blagjoevich’s plans for 300% parental Medicaid & 400% subsidized insurance levels were blocked by the legislature & the courts. Yet he refused to force patients into HMOs, raised the working disabled level to 350%, made private plans let children stay covered to age 26, required that Medigap policies be sold to the disabled as cheaply as the costliest ones are to the aged & raised pediatric specialist fees. A big Cook Co. Hosp system shortfall that threatened service cuts was largely averted. But a $100 million deficit forced the U of Chicago Med. Center to close its women’s & dental clinics and another shortfall forced the U of IL at Chicago to close a clinic too. The state found $640 million to subsidize safety net hospitals, made hospitals give discounts to the uninsured & funded a hospital “assessment” fee plan to bring in $450 million more in US matching. With a huge deficit, the final budget made deep health cuts--yet HIV funding was cut by only 3 to 4% (with the non-ADAP HIV budget cut--to be used instead to meet expected ADAP cost increases).

Indiana---this 209(b) state’s token SPAP for those under 150% excludes the disabled; and it 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) and the regular parental level is 20%/26% if working (2008). Gov. Daniels (R) & the old all-GOP legislature raised CHIP premiums. The risk pool has a Medicare supplement and a low income premium discount. The ACLU sued to void a once-every-6-yrs denture & re-linings limit. Advocates & many House (now D) members opposed Daniels’ now-cancelled, troubled IBM privatization contract (but he may still use some IBM sub-contractors for similar tasks). A federal class action suit was filed to correct improper case closings, appeals & other eligibility failings by the contractor. The state ADAP (with a 300% level) may have to start a waiting list. The state raised the CHIP level from 200 to 300%. A waiver subsidizes insurance for parents below 200%--and it even has limited slots (just raised by 5,000 to 42,000) for childless, non-disabled adults under 65 (but over 100,000 have already applied). The insurance offers HMOs, preventive care, few co-pays; yet no dental or vision care. Patients must put 2%-4% of income in HSAs. “Richer” non-Medicare adults (up to the cap on the childless) can buy in with unsubsidized premiums. See http://www.cbpp.org/1-24-08health.htm , “Healthy IN...” at www.kff.org & “Profiles: Healthy IN...” at www.statecoverage.net . The deficit is $763 million & may require an ADAP waiting list. Daniels plans to cut MD, DDS, nursing home & hospital fees by at least 5%. The St. Vincent chain of 17 hospitals eased its indigent free care & discount rules. The state lets more providers screen for breast & cervical cancer --so more uninsured women under age 65 who screen positive (even if they’re childless or non-disabled) can get Medicaid

Iowa---A waiver covers non-Medicare adults—even if childless & non-disabled—under 200% at 2 public hospitals. The aged/disabled level is $674/mo (the SSI rate), the parent level is 29%/86% if working (2008) & ADAP’s is 200%. The risk pool has a Medicare supplement but no low income premium discount. The deficit is $565 million & the state cut hospital rates $18 million. Gov. Culver & the legislature (both D) made private plans let children stay enrolled to 25, covered 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 care only. He supported bills to let localities & non-profits join the state worker health plan (small firms were dropped). A bill to widen Medicaid mental health care died & an ADAP waiting list was started 

Kansas---this Title XVI state has an aged/disabled level of $674/mo (the SSI rate), a parent level of 27%/34% if working (2008), a 200% CHIP level & a 300% ADAP level. The legislature (R) passed a bill promoting HSAs & raised provider fees to between 65% & 83% of Medicare’s. Blue Cross & a foundation subsidize insurance for KC-area families under $30,000. The risk pool has no low income premium discount and bans Medicare eligibles. Ex-Gov. Sibelius (D) covered the working disabled, ”ex- disabled” & “pre-disabled”, offered state mini-COBRA rights and raised low income clinic subsidies. She also signed a bill authorizing Medicaid for parents under 50% by 2009 & all adults under 100% by 2012 and one to study an insurance subsidy for those under 200%. The legislature funded raising the CHIP level to 250% (yet the numbers of uninsured children rose from 20,000 in 2005 to 70,000 in 2008), but it refused to fund the planned parent & adult expansions or the hiring of enough new state eligibility workers to reduce a 12,000 application backlog left by a private contractor. Gov. Parkinson’s (D) Medicaid staff is considering a 10% provider fee cut; more use of pre-authoriza-tion for some services; charging co-pays for unnecessary ER use; raising CHIP premiums $10 to $20; starting an Rx man-agement program for mental health Rx’s; and raising MD fees to 84% of Medicare rates. There’s a $238 million deficit. 

Kentucky--- has an aged/disabled level of $674/mo (the SSI rate), a parent level of 36%/62% if working (2008), a 200% CHIP level & a 300% ADAP level. The legislature (R Sen.; D House) dropped tough, yet unworkable, nursing home & HCB medical admission rules; capped Rx’s at only 4/mo, limited occupational, physical & speech therapy, x-rays & MRIs; raised co-pays; and divided Medicaid into 4 different groups: “healthy” adults; children; aged & disabled; and MR & DD patients: See http://www.kff.org/7530.cfm . The state raised child DDS fees. The risk pool has no low income premium discount or Medicare supplement. Gov. Brashear (D) faces a $242.5 million rise in Medicaid/CHIP costs in 2010. He signed a 60-cent tobacco tax to avert Medicaid & CHIP cuts & enrolled 22,000 more children in CHIP. There’s a quickly-growing ADAP waiting list (with about 100 on it) and client co-pays & a formulary reduction may be needed. 

Louisiana---has an aged/disabled level of only $674/mo (the SSI rate), a parent level of 12%/26% if working (2008) & a 200% ADAP level. Its risk pool has no low income discount & bans Medicare eligibles. The legislature (D) voted to raise CHIP’s 250% level to 300% but lacks funds to do so. Gov. Jindal (R) urged CMS to forgive a $771 million overpayment (but CMS wants $362 million of it back now) & seeks a waiver to put patients in HMOs & subsidize insurance for parents under 50% in N.O., Baton Rouge & Shreveport plus all adults under 200% in Lake Charles. See “LA’s Med. Waiver..” at www.cbpp.org  He proposed $531 million in health cuts: reducing covered Rx’s from 8 to 5 monthly (unless more are “medically justified”) & cutting MD & hospital rates. He’s refusing $9.5 million in US stimulus funds to cover working ex-welfare parents. The state matching rate falls 9% by 2011 (for a loss of $700 million in US funds); 2009’s Medicaid shortfall is $308 million; the 2010 deficit will be $1.7 billion; and the state plans another $232 million provider fee cut.    

Maine---Gov. Baldacci & the legislature (both D) subsidize insurance for those under 300% and raised the childless adult Medicaid level to 100% (but it’s closed to new non-disabled, non-aged clients) & for parents to 200%/206% if working. There’s a 500% ADAP level, a 200% CHIP level & SPAP levels of $1,604/mo for 1 & $2,159/mo for 2 & a waiver for O/P care of HIV+ (even “pre-disabled”) patients under 250%. There’s no risk pool. Baldacci proposed an employer play or pay rule, reforming hospital funding & starting risk pool & reinsurance plans. Adult dentistry is skimpy (but dentures are covered). There are no MSP asset tests & the QMB income level is 150%, SLMB’s is 170% & QI’s is 185%. Baldacci raised cost-sharing for those over 150%, cut podiatry care & charged “richer” clients $25 premiums. With a $140 million deficit, the legislature cut health & welfare funds $34 million & may slash $25 million more & start an ADAP waiting list. 

Maryland---has an aged/disabled level of only $674/mo (the SSI rate), a parent level of 116%, a CHIP level of 300%  (but with a 6 month waiting period for some new applicants) & an ADAP level of 500%. An appeals court upheld AARP’s & Legal Aid’s suit to widen the state’s overly-strict nursing home, HCB waiver & at-home care medical qualifi-cation & appeal rules. A waiver merged the main SPAP & a state low income clinic program into one O/P care & Rx program for all non-Medicare adults (even childless & non-disabled) under 116%. A state-sponsored, Blue Cross-run 2^nd SPAP (with a 300% level) covers some Pt D donut hole expenses & premium costs, but seems to exclude the disabled. A child’s untreated tooth infection spread to his brain & killed him, so UnitedHealth funded an indigent child care program at the state dental school. The risk pool liberalized its low income premium discounts for those under 200%, yet has no Medicare supplement; and the state covers the working disabled. Gov. O’Malley & the legislature (both D) made private plans let children stay covered to age 26; raised the income level to 116% for full Medicaid for all parents (enrollment has already doubled projections & costs $50+ million/yr); subsidize insurance for some low paid small firm workers and gave $50 million to avert closing of Prince Georges Co. Hosp., where 1/2 its patients are indigents. Baltimore’s Bon Secours Hosp., with high indigent costs too, seeks $5 million to stay open. First the state cut Medicaid by $82+ million, including nursing home, home health aide, private RN & HMO fees and community services funding for the disabled; and cut hospital rates to 80% of private insurer rates. Then an expected $2 billion deficit forced O’Malley to scrap a planned expansion of full Medicaid to all childless (even non-disabled) adults under 116% and to lead a state budget board to cut $90 million more in health funds (slashing fees to Medicaid providers, HMOs, HCB waiver programs & community care organizations and cutting pay for disabled clients’ personal care aides by 2%). Now he plans still another $300 million in health cuts--including closure of a state psychiatric hospital. He is funding a $42 million child dental fee raise, is carving child dentistry out of HMOs for direct state managing & signed bills making hospitals give free care to those under 150%.

Massachusetts---has no risk pool. Ex-Gov. Romney (R) signed the legislature’s (D) bill to expand Medicaid; require everyone to have insurance; subsidize it for small employers & workers under 300%; increase the CHIP level from 200 to 400%; and raise the parent—but not the childless aged (now only 100%) & disabled (now only 133%) –Medicaid level to 200%. The ADAP level is 488% & the SPAP’s is 188% (but up to 500% for Pt D patients). Gov. Patrick (D) cut cost -sharing for “Free Care” patients under 200%. But with a deficit of $1.2 billion & a $200-$300 million projected Medicaid shortfall for 2009 (plus even bigger ones for 2010 & 2011), he boosted Medicaid & subsidized health program premiums & co-payments; raised SPAP cost-sharing $11 million; proposed freezing MD & hospital fees; and is cutting $74 million for substance abuse, tobacco cessation & school RNs and $20 million for pregnancy prevention. The legislature voted to end adult dental benefits & drop coverage of 31,000 legal aliens. Patrick may yet salvage some adult dentistry but had to restrict the aliens to hospital emergency & limited low income clinic care, and with the still-rising budget shortfall now at $575 million proposed dropping most adult dentistry (including dentures); raising some MD co-pays to $6; prior approval for costlier psychiatric Rx’s; ending personal attendant care for those who now get it less than 15 hrs/wk; raising generic Rx co-pays by $1 & brand name Rx co-pays to $6; eliminating nursing home pre-screening; and cutting daily hospital fees after 20 inpatient days. The Boston Med. Cntr faces a 2010 loss of $100 million from low state fees & is suing the state. A state program to pay COBRA premiums for the unemployed who can’t get other coverage exhausts its funding by 1/10; so Patrick seeks to double the employer tax funding it to continue coverage of such otherwise-uninsured unemployed persons  

Michigan---has no risk pool; an aged/disabled level of 100%, a parent level of 39%/66% if working (2008), a CHIP level of 200% & a 450% ADAP level. It ended adult dental, hearing aid, podiatry & chiropractic coverage and ceased enrolling new cases in its O/P care-only waiver for childless, non-disabled adults. Gov. Granholm (D) & the old all-GOP legislature raised cost sharing, restored adult dentistry and raised child wellness, dental & adult preventive fees. Counties containing Flint, Lansing, Muskegon & Detroit offer coverage for those under 200%. With a $2.8 billion deficit & a caseload grown a ½ million in a year, the House (now D) & Senate (still R) agreed to cut Medicaid $165 million, with 8-12% cuts in MD, hospital & mental health fees; again ended adult podiatry, chiropractic & dental benefits (after an untreated tooth infection killed a patient, a suit was filed); and dropped adult vision care. The Senate rejected a 3% MD tax that Granholm sought.   

Minnesota---this 209(b) state has an aged/disabled level of about 100%, a CHIP level of 275%, an ADAP level of 300% and a risk pool with low income premium discounts for those under 200% & a Medicare supplement. It raised premiums & co-pays for Medicaid, CHIP & MinnesotaCare (Medicaid-subsidized insurance for adults under 275%) and denied Medicaid & CHIP to legal aliens. Gov. Pawlenty (R) ended ADAP co-pays; funded an Rx discount plan for uninsured & Pt D donut hole patients; and covered the working disabled. With a $4.63 billion deficit, he cut hospital rates $90 million & capped enrollment in HCB care for the disabled. Then he proposed cutting funding for personal aides for the disabled and tightening medical qualifications & hours of coverage for personal attendant, nursing home & HCB waiver care; reducing community support services; slashing basic medical care costs; raising some clients’ premiums; ending coverage of occupational & speech therapy and audiology; dropping adult dentistry & dental critical access payments, dropping childless adults from MinnesotaCare; ending parents’ MinnesotaCare (they’d have to seek Medicaid by meeting much lower TANF or medically needy income levels); and cutting parent asset levels. The legislature (D) forbade hospitals from pre-screening patients for unpaid medical debt & its budget bills would cover 20,000 more children and reject or cancel Pawlenty’s cuts; but he then proposed $236 million more in health cuts (including more nursing home fee cuts), will likely veto the legislature’s bills; line-item vetoed all funding of state General Medical Assistance (dropping 30,000 patients); and proposed limiting Medicaid & MinnesotaCare patients to public clinics to save $100 million. Hennepin Co’s Med. Ctr may end free care for other counties’ indigents & cut mental health, dental & HIV services. Minneapolis’ MN Children’s Hosp.& Clinics, with 40% of its funding coming from Medicaid & CHIP, is curtailing various programs.     

Mississippi---has no spend down; its risk pool has no low income premium discounts & no Medicare supplement. Gov. Barbour (R) cut the aged/disabled level from $1,000+ to $674/mo (the SSI rate). The parent level is 25%/46% if working (2008), CHIP’s is 200% & ADAP’s is 400%. Only 2 brand Rx’s & 3 generics are allowed monthly (HIV patients get 5 brand Rx’s & there’s a suit against the limits). Barbour cut Rx fees & physical, speech & occupational. therapy benefits, but since a TV station exposed strict limits for even children to get speech therapy, officials now claim to have relented. An in-person re-application rule retards enrollment. He & the Senate (D) won’t drop it (except maybe for LTC clients), but the House (also D) would do so. With a budget shortfall, Medicaid needs $268 million more in 2010. Barbour pledged not to cut it (but may add premiums & raise co-pays) & sought new cigarette & hospital taxes. Yet he vetoed $7 million to pay Medicaid fees to community mental health centers for care already given & apparently neither he nor the legislature has funded the state share of Medicaid fees for the centers’ ongoing care either. The state cut druggist fees; but court order voiding the cut was upheld by the state supreme court after they sued to overturn it. A tobacco tax passed & the hospitals agreed to a $60 million/yr tax (rising to $90 million) to fully fund Medicaid, which both Houses passed & Barbour signed.  

Missouri---a 209(b) state; its risk pool has no Medicare supplement but has a low income premium discount. The GOP legislature cut the aged/disabled level from 100 to 85%; ended medical assistance for those awaiting SSA disability awards; dropped the working disabled; cut the parent level to 20%/26% if working (2008); ended adult dental, podiatry, hearing aid & vision benefits; raised CHIP premiums; denied CHIP to those whose job plans cost under 5% of income (with exceptions); but kept the ADAP & CHIP levels at 300% & raised the SPAP (which now covers the disabled on Medicare) level to 150%. Blue Cross & a foundation subsidize insurance for KC-area families under $30,000. The state raised & more strictly enforces non-ER co-pays; used “premium support” to pay clients’ job plan premiums rather than give them secondary Medicaid; restored hospice & working disabled coverage (the latter only for those with low SSDI awards); gave birth control & screenings to women under 185%; restored adult vision (except for nursing home aged), hearing aid & podiatry coverage; and let the aged & disabled opt out of HMOs. A court made the state widen notice & hearing rights before CHIP terminations; and the state lets clinics enroll children. Gov. Nixon (D) asked the legislature (still R) to partially restore the parent level up to 50% (it refused); cover all adults’ dental, hearing & vision care (also rejected); liberalize CHIP premiums & coverage (killed too) and let over-income children buy into CHIP (its response isn’t yet known). A big deficit & 40,000 more patients already added to Medicaid since 1/09 killed his plans to raise the aged/disabled level back up to 100% and for more proactive enrollment outreach to the uninsured. He had to seek a cut of $139 million in hospital rates---plus $32 million in other Medicaid cuts (including lower MD & DDS fees); cuts in mental health care, other hospital funding & lower public clinic subsidies; and is considering an ADAP formulary cut & co-pays 

Montana---has an aged/disabled level of $674/mo (the SSI rate), a parent level of 35%/58% if working (2008) & an ADAP level of 330%.Its risk pool has low income premium discounts for those under 150% & a Medicare supplement. The state raised cost-sharing, cut LTC & hospice benefits & access and aged/disabled MD visits to 10/yr. Gov. Schweitzer (D) & the legislature (R Sen; tied House) ended a CHIP waiting list (but ADAP now has one); seek a waiver to cover 3,000 more (maybe even childless non-disabled) adults; raised the family asset level; began a SPAP for Medicare patients under 200%; raised the CHIP level to 175%; widened CHIP dental & preventive care; and made private plans offer vaccines & well-child care up to age 7 & let children stay covered to age 25. A referendum authorized $20 million to raise the CHIP level again to 250% & merge it into Medicaid on 10/1/09, but a bill to let CHIP cover contraception died. 

Nebraska---is a Title XVI state with a one-house “non-partisan” legislature. Its aged/disabled level is 100%, its parent level is 46%/58% if working (2008), its CHIP level is 185% & its ADAP level is 200%. It ended Medicaid for many parents who leave welfare to work (but a court barred denying Medicaid to those who don’t meet go-to-work rules). The risk pool has a Medicare supplement but no low income premium discount. Gov. Heineman (R) covered Pt. D co-pays for HCB & board & care clients and signed bills letting children remain dependents on private plans until 30 & raising the 185% CHIP level to 200%. With a $334 million deficit, he’s considering provider fee cuts, limiting dental care to $1,000   yearly, hearing aids to 1 each 4 yrs, eyeglasses to 1 pair each 2 yrs, and adults to 12 chiropractic visits and 60 sessions of occup., speech & physical therapy per year. There’s a 75 client waiting list for ADAP & Ryan White Act-funded services. 

Nevada---a Title XVI state with no spend down & no risk pool; its disabled level is $674/mo (the SSI rate), while the aged-only level is about $710.40 (their SSI/SSP rate); its parent level is 26%/91% if working (2008); its CHIP level is 200% & its ADAP level is 400%. It covers the working disabled. Its SPAP, with a 225% level, covers the disabled & even vision care; but it raised CHIP premiums. A $2.8 billion deficit, with Medicaid now $128 million over-budget---got Gov. Gibbons (R) to ask the legislature (D) to cap CHIP dental care at $600/yr, end CHIP orthodontia & vision care, tighten SNF, ICF, HCB waiver & at-home care medical admission rules, reduce pregnancy coverage, cut hospital I/P fees 14%, & O/P rates 5% (closing the U. NV at LV  Hosp.’s dialysis & oncology clinics), slash HCB care fees; drop adult dentistry; cut personal care funds for the disabled; consider limiting non-emergency transportation & mental health benefits; slash I/P hospital neonatal rates 24% & pediatric specialist fees 41%; and cut all hospital I/P rates 10% more. NV makes its counties fund almost all hospital uncompensated care, causing inadequate, unfair hospital funding--leaving 5 big indigent-treating hospitals with no subsidies. Rising Rx costs forced the HIV agency to cut LV-area client services by $1 million  

New Hampshire---a 209(b) state; its a risk pool has no Medicare supplement but recently added low income premium discounts for those under 250%. Its aged/disabled level is $714 (the SSI/SSP rate), its parent level is 63% (2008), and the CHIP & ADAP levels are 300%. The state has a much-stricter-than-SSI “209(b)” Medicaid disability rule (inability to work for 4+ years) & doesn’t cover hospices. Gov. Lynch & the legislature (both D) shifted some state LTC costs to counties & ended a DD care waiting list. He cut Medicaid $29 million & then the legislature’s budget made even more cuts –in hospital, MD & mental health fees. The deficit is $75 million; federal auditors are seeking a refund of $35 million in DSH costs they say were over-claimed by the state, and FY 2009’s Medicaid costs are running $7.6 million over its budget. The state made private plans let children stay covered to age 26 & now even lets 19-to-26-yr-olds buy into CHIP. 

New Jersey---has no risk pool, an aged/disabled level of 100%; an ADAP level of 500%, and SPAP levels of $31,850 for 1 & $36,791 for 2.; A waiver covers others (even childless & non-disabled) under 100%. Gov. Corzine & the legislature (both D) required coverage of all children, made insurers let them stay on parent plans to age 31 & raised the parent level to 200%. Public Citizen said NJ provider fees were the US’ lowest, so the state raised many pediatric rates. One audit questions $52 million in school health costs & a 2nd said hospital indigency programs fail to collect millions from other liable payers. Some assisted living facilities won’t let patients stay using Medicaid when their funds run out. Blue Cross sells a cheap CHIP-like policy to those over its 350% level With a $3.5 billion FY 10 deficit, Corzine signed a budget that cut hospital charity & teaching and adult day health center fees, avoided ADAP & Medicaid Rx co-pays, kept the 200% parent level, ended CHIP premiums for those under 200%, enrolled uninsured newborns in CHIP upon hospital discharge, limited the SPAP formulary (its co-pays had already been raised) and increased MD fees & low income clinic funding. 

New Mexico—has no spend down, but has a risk pool with a Medicare supplement & low income premium discounts for those under a newly-raised 400% level. Its aged/disabled level is only $674/mo (the SSI rate), its parent level is 30%/69% if working (2008), CHIP’s is 235% & ADAP’s is 400%. There’s a waiver that covers any adult (even if childless or non-disabled) under 200%. Gov. Richardson (D) had proposed raising the waiver level to 300 or 400% & covering all--even childless & non-disabled--adults in it; and a 300% CHIP level. Medicaid’s shortfall will be $300 million by 1/1//11 (it’s $40 million now), so he & the legislature (D) dropped expansion plans; limited enrollment in waiver coverage of adults under 200%; and may end adult dental, vision, hearing aid & hospice coverage; slash physical, occupational & speech therapy; cut mental health/substance abuse benefits & provider fees; and cut or drop Rx coverage & HCB waiver services. 

New York---has no risk pool. A “FamilyHealth” waiver covers parents under 150% & childless (even non-disabled) single adults under 65 below 100% (150% for couples). The childless aged singles’ level is $761/mo & ADAP’s  is 431%. The state subsidizes insurance for workers under 250%, but caps plan Rx benefits at $3,000/yr. The legislature (with both Houses now D) excludes the disabled from the SPAP (which has a 350%+ level); won’t cover digital mammograms; raised Rx & MD co-pays (capping them at $200/yr); adopted a loose formulary; covers assisted living, chore aide & adult day care; makes counties pay 1/2 of state Medicaid costs (but caps their cost increases at 3.5%/yr); lets providers deny services to those who don’t meet co-pays; funded HIV day health care; covered colon & prostate cancer patients and the working disabled under 250%; required hospital bill discounts for those under 300% & banned taking debtors’ homes; passed mental health parity; and raised the CHIP level from 250 to 400%. Public Citizen said MD fees were the US’ 2^nd lowest, so the state began to raise its fees to 70% of Medicare’s. Ex-Gov. Spitzer (D) started to let small firms that can’t afford insurance buy into FamilyHealth at low rates. With a $15+ billion deficit, Gov. Paterson (D) signed a $1 billion hospital & nursing home fee cut; sponsors Rx discounts for the disabled; raised asset levels for all clients ($13,050 for 1, $19,200 for 2, etc); ended MSP asset tests; extended COBRA rights for all ex-workers & dependents to 36 months; but he seeks another Medicaid & mental health cut of $471 million; to slash HIV care $6 million; and to force NYC HIV & all dually-eligible patients into HMOs. He’d make private plans let children stay covered to age 29 ; raise the level for all adults to 200% (but only if & as funds permit); but proposed a $65 million cut in funding for group homes & still another round of nursing home fee reductions. Short $316 million, NYC’s public hospitals plan to cut child mental health & O/P Rx benefits and close some clinics--while NYC proposes to end its school dental program & did cut some HIV services. The City of Buffalo is cutting funding for---and thereby possibly causing the closure of—two low income health clinics.  

North Carolina---covers the working disabled, but allows only 8 Rx’s a month (plus another 3 or more on an exception basis).Its aged/disabled level is 100%; its parent level is 37%/51% if working (2008); its CHIP level is 200% (the deficit blocked plans to raise it) & ADAP’s is 300%. The SPAP– which excludes the disabled—subsidizes Pt. D premiums for those under 175% not on full Extra Help. The UNC Hosp. eased its indigent care rules. The state had made counties pay 15% of Medicaid costs, but ex-Gov. Easley & the legislature (both D) shifted their costs to the state as of 7/09. They set up a 2^nd SPAP for ADAP clients on Medicare who are not eligible for Pt D’s full Extra Help, passed limited mental health parity & started a risk pool that excludes Medicare patients, requires pre-authorization + a $250 co-pay for “specialty” Rx’s, has a $100,000/yr out-of-pocket maximum but just got a $1.5 million CMS grant to fund low income premium discounts. With a $2 billion deficit, Gov. Perdue (D) proposed closing 50 state mental hospital beds. The budget cuts MD & hospital fees $76 million; home personal care $55 million (with an 18 hr/wk limit); adult dentistry 50%; community mental health $250 million; care for the uninsured $40 million; and mental health provider fees 5%. It slashes audiology; speech, physical & occup. therapy; reduces hospice funding; cuts $3 million in state ADAP funding; ends Medicaid’s HIV case management program; stops covering cough & cold Rx’s & many child dental X-rays & sealants; limits diabetic sup-plies to 1 provider; and requires prior approval for X-rays, MRIs, MRAs, PET scans, ultrasounds & even EPSDT services 

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 100%, its parent level is 45%/62% if working (2008) & its ADAP level is 400%. Gov. Hoeven (R) signed bills to cover disabled children via the FOA (only up to 200%), boost the CHIP level from 140 to 150% & raise the Medicaid medically needy level—which is also the level excess-income clients spend down to--from $500/mo to $750/mo for 1 person. He proposed raising the CHIP level again to 200% (but the GOP legislature refused), streamlining nursing home, HCB waiver & home care access and raising MD fees; but may have to cut the ADAP formulary & cap its costs. 

Ohio--this 209(b) state with no risk pool cut the parent level from 100% to 90% and has a 500% ADAP level. It slashed adult dental funds 50%; cut secondary fees for dual eligibles & medical aid for those awaiting SSA disability awards; moved most patients into HMOs (some with too few specialists); let providers turn away those who don’t meet co-pays; and passed mental health parity--but kept its aged/disabled level at only $534/mo (the US’ very lowest!). Gov. Srtickland (D) & the legislature (R-Sen; D House) raised CHIP’s level from 200 to 300% (to be effective only when a lawsuit allows) & covered disabled children under 500% via the FOA. He got a waiver to cover assisted living, lets over-income children buy into CHIP,cut funds for county eligibility work and SNF & ICF fees (which the legislature partially restored;  it also bolstered home care; and is considering a bill to widen access to HCB waiver care that its bipartisan sponsors say can save Medicaid $900 million/yr). With a huge deficit (and a court ban on spending $250 million in tobacco funds on Medicaid), he delayed MD, DDS & hospital fee raises and full restoration of adult dentistry--and may cut the ADAP level & impose co-pays. For a mere $4 extra fee, he forced nursing homes (instead of the state) to pay for any physical therapy, wheelchairs & medical equipment their patients need; and got the legislature to impose $718 million in hospital “fees”. He also proposed making private plans let children stay covered to 29 & extending state mini-COBRA rights to small firms.  

Oklahoma---this 209(b) state has a risk pool with no Medicare supplement or low income premium discount. It cut the aged/disabled level from 100% to about $720 (the SSI/SSP rate). The parent level is 32%/48% if working (2008) & ADAP’s is 200%. It abolished its parents & children spend down, has a 3-Rx’s/mo limit & doesn’t cover hospices. Gov. Henry (D) covered the breast/cervical cancer & working disabled groups, and got a waiver to subsidize insurance for workers & spouses under 200% in small firms. Employer eligibility was later widened, college students under 200% can now enroll & the legislature (R) made the insurance subsidy more affordable—but with stripped-down coverage exempt from the original, stronger minimum benefits law. It also authorized Medicaid coverage of assisted living; streamlined enrollment red tape, raised the CHIP level from 185 to 300%; encourages employer plan & maybe even Medicaid HSAs; gutted the insurance minimum benefits law; and promotes primary & home care over ERs & nursing homes--but widened mental health coverage. The deficit is $612 million & the ADAP had to adopt economies. With a $26.6 million Medicaid budget cut, the state may have to drop such coverage as dental benefits for pregnant women, durable medical equipment, nebulizors & blood glucose monitors; reduce fees for hospitals, MDs & other providers; raise co-pays; and limit ER visits.   

Oregon---this Title XVI state’s risk pool has no Medicare supplement but has low income premium discounts for those under 185%. Its income levels are $674/mo for the aged & disabled (the SSI rate), 100% for parents, 185% for CHIP & non-Medicare adults’ insurance subsidies & 200% for ADAP. An anti-tax referendum cut eligibility (except for HIV & transplant cases), limited adult dentistry & ended adult vision care. The OR Health Plan waiver--with limited benefits for non-Medicare childless & non-disabled adults under 100%--is again taking applications but then enrolls only those found eligible who can also win a lottery. The ADAP has cost-sharing. Gov. Kungoloski & the legislature (both D) took the FOA option and---with a big deficit—imposed taxes on insurers & hospitals to cover 80,000 more children (with CHIP’s level raised to 300%) & 35,000 more adults & offer more in-home care (but right wing groups favor a repeal referendum). 

Pennsylvania---has no risk pool, an aged/disabled level of 100%, a parent level of 27%/36% if working (2008), a CHIP level of 300% & an ADAP level of 350%. It subsidizes “AdultBasic” insurance (with no mental health or Rx benefits & a waiting list of 270,000+) for non-Medicare adults under 200%. With income levels of $23,500 for 1 & $31,500 for 2, the SPAP excludes the disabled. Gov. Rendell (D) covered the working disabled & seeks to return HMO Rx benefits to state control to get $95 million in rebates. He raised the SPAP levels to $23,500 for 1 & $31,500 for 2, enough to cover 90,000 more seniors (but still not any disabled); and signed bills making private plans let children stay covered to age 30 and applying 9 month state mini-COBRA rights to small firms. He called for cutting hospital rates $75 million; but Senate (R) leaders want to cut hospital rates more & even to freeze CHIP funding (just as caseloads are rising). Public Citizen says PA MD fees are the US’ 5^th lowest. The deficit is $3.2 billion. A shortfall forced Philadelphia city clinics to start charging $5 to $20 fees & to close some sites. Northeastern Hosp. (with 1/2 its patients on Medicaid) has to close. The House (D) twice voted to expand AdultBasic (to cover 85,000 more patients and add Rx & mental health benefits: ½ to be funded by US matching and ½ by new state taxes). But Senate GOP leaders oppose raising taxes on the rich, as Rendell called for to bolster CHIP & Medicaid and fund the SPAP & the proposed AdultBasic expansions. CMS’ own current fee cuts--smaller than the cuts in Democratic reform bills—for Special Medicare Advantage plans for dual eligibles in metro Philadelphia  caused Blue Cross & other insurers to drop out, throwing 17,000 patients back into fee-for-service Medicare & Medicaid   

Puerto Rico----its matching rate is capped below what states get. It claims there’s no ADAP waiting list (its income level is 200%). ADAP reviews & audits report inadequacies in care, unaccountability, mis-management & fiscal irregularities 

Rhode Island---has no risk pool, an aged/disabled level of 100%, a parent level recently cut from 185 to 175%, a CHIP level of 250% & an ADAP level of 400%. It covers the working disabled and its limited formulary SPAP covers the aged but only those disabled over age 55 (its income levels are $37,167 for 1 & $42,476 for 2). Gov. Carcieri (R) signed bills to  require free & discounted hospital care for those under 200% & 300%;and ban taking homes from hospital debtors. Public Citizen says MD fees are the US’ 3^rd lowest. Big deficits ($660 million in FY10) moved him to get a CMS waiver with extra up-front federal funding that in exchange requires the state has to divert 12% of nursing home cases to cheaper home care & accept a cap on future US funds that could deny nursing home care to all but the “highest need” clients and force premiums up. The legislature (D) raised adult daycare co-pays, dropped legal alien children & 7,400 adults--and approved the waiver. See www.povertyinstitute.org  & “RI’s Medicaid Proposal….” at www.cbpp.org; and email lkatz@ric.edu for critiques. The Medicaid chief said more cuts (e.g., dropping eyeglass benefits & 40,000 more clients) may come. Carcieri proposed abolishing the SPAP for those over 65; ending parents’ dental coverage; and cutting nursing home fees 5%. 

South Carolina---has no spend down. Its aged/disabled level is 100%, its parent level is 49%/90% if working (2008) & its ADAP level is 300%. Its risk pool has a Medicare supplement but no low income premium discount. Gov. Sanford & the legislature (both R) limited Rx’s to 4/mo, are moving clients into HMOs (yet allowing opt-outs) & raised CHIP’s level to 200%. The SPAP has a 200% level but excludes the disabled. The deficit is $500+ million. The legislature cut Medicaid mental health benefits; closed an HIV program to new clients; reduced home health, hospital & nursing home funding; cut SPAP benefits (but by less than Sanford urged), yet passed a mental health & substance abuse parity law for private plans.  

South Dakota---has no spend down & a risk pool with no low income premium discount that excludes Medicare patients. Its aged/disabled level is $674/mo (the SSI rate), its parent level is 54% (2008) & ADAP’s is 300%. Rejecting a health panel’s call for eligibility expansion, Gov. Rounds & the legislature (both R) refused to raise the pregnant woman level to 200% or CHIP’s 200% level to 250% or boost provider fees (but a legislative board is studying Medicaid rates) and ended adult dentistry. 2010’s deficit will be $81 million; 2012’s will be $200 million; and an ADAP waiting list had to be started  

Tennessee----Gov. Bredeson (D) & the legislature (R) dropped 191,000 clients when they ended the Tenncare liberalized-eligibility waiver expansion. The aged/disabled level is now $674/mo (the SSI rate), the parent level is 73%/134% if working (2008) & the ADAP (which now has a waiting list) has a 300% level. Except for pregnant women, children & HIV+ patients, MD visits were cut to 10/yr; hospital days to 20/yr; and Rx’s to 2 brand drugs/mo + 3 generics/mo, except for certain serious conditions. There’s a 250% CHIP level, a risk pool (with no Medicare supplement, but with a premium discount for those below 250%) & a SPAP (with a waiting list) covering up to 5 Rx’s/mo (for generics only & with a low benefits cap) for non-Medicare patients under 250% and state-subsidized barebones insurance for non-Medicare patients under $55,000 (with $60-$120/mo premiums). Besides also covering diabetic items & more psychiatric Rx’s, CHIP uses Medicaid’s Rx rules. The spend down was restored, but Bredeson cut its budget--and the home care & medical equipment budgets---plus benefits promised to the disabled who lost Tenncare. The deficit may be $1.25 billion & bring cuts--first of $400 million & later $360 million more. An HMO tax may raise $300 million but Bredeson may limit Medicaid patients to $10,000/yr of hospital care, end occup., speech & phys. therapy benefits and cap yearly ADAP costs. He got a US court to drop a 1987 order grandfathering-in 150,000 ex-SSI recipients to Medicaid (most are ineligible under today’s regular rules) & the state is now terminating clients it finds ineligible under those rules; see “Daniels Case” at www.tnjustice.org  

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 13%/27% if working (2008) & the ADAP & CHIP levels are 200%. Gov. Perry & the legislature (both R) dropped coverage of  CHIP prostheses, physical therapy & private duty nursing; raised CHIP co-pays & premiums; cut Medicaid home health; ended adult chiropractic & podiatry care; capped Medicaid Rx’s allowed monthly; moved patients into HMOs (but, after many quality of care questions, cancelled one big HMO contract for the aged & disabled); began contracting-out eligibility determinations (with many complaints) and restored Medicaid mental health, vision & hearing aid coverage and CHIP mental health & dentistry (limited adult dentistry is covered, but dentures & multiple extractions need pre-authorization); mandated some mental health parity in private plans; started a SPAP just for HIV clients; and seeks a waiver to insure parents under 133%, childless, non-disabled adults under age 65 below 100% & maybe later even all non-Medicare adults under 200%. See http://www.hhs.state.tx.us/Medicaid/Reform.shtml . A non-profit (www.TexHealthCoalition.org) fosters subsidized discount health plans ($40-$120/mo premiums) for workers (but not dependents) under 300% in small firms in the Brazos Valley, Dallas, El Paso, Ft. Worth, Galveston & Houston. A court order to improve children’s care will require higher MD & DDS fees (but adult rates remain too low). The House voted to cover disabled children under 400% via the FOA but killed a bill raising CHIP’s level to 300%, while action on a bill restoring Medicaid’s adult spend down is unclear. The $3.1 billion deficit includes a $1 billion rise in Medicaid costs from caseload growth. State-funded, privatized mental health costs rose 17%, yet the contractor cut its budget $10 million 

Utah—a Title XVI state with a risk pool--with a low income premium discount, but no Medicare supplement. Its aged/ disabled level is 100%, its parent level is 48%/68% if working (2008), CHIP’s  is 200% & ADAP’s is 400%. A waiver gives limited O/P care, but with big co-pays, to non-Medicare adults (even if childless or non-disabled) under 150%. The legislature (R) ended coverage of podiatry, audiology & speech therapy, chiropractic, outdoor wheelchairs & adult eye-glasses & dentistry (even after an untreated tooth infection spread to one patient’s brain & killed her); cut hospital & child DDS fees 25%; and may cut CHIP dentistry more. Ex-Gov. Huntsman (R) began a subsidized premium program for some small firm workers under 200% (see “New CHIP /UPP Waiver..” at www.healthpolicyproject.org) & named an insurance reform board that may suggest community rating & malpractice “reform” A 2^nd  legislative  reform panel would also gut the minimum benefits law; ban preexisting condition rules; get insurers to offer cheaper-than-COBRA policies (this was enacted); and urge employers to offer workers HSAs over regular insurance. The deficit is $272 million. Gov. Herbert (R) & the legislature started an ADAP waiting list (12 clients are now on it & 100 others were apparently just dropped). They may end occupational therapy benefits; cut the income level for the disabled from 100 to 74% (the $674/mo SSI rate), reduce school health funding & drop the medically needy/spend down option. The 2010 budget cuts Medicaid $51 million   

Vermont—has an aged/disabled level of 125% & a parent level of 185%. The CHIP level is 300%, ADAP’s is 200% & the SPAP’s is 175%. The state subsidizes insurance for others under 300%. The legislature (D) reversed most of Gov. Douglas’ (R) adult dental cuts (but dentures still aren’t covered & there’s a $495/ yr cap). A waiver, in return for more US funds, puts patients into HMOs & favors HCB care over nursing homes--but caps future US matching funds. There’s no risk pool.  There’s a $100+ million shortfall. Douglas pledged to not cut eligibility, yet raised some SPAP co-pays and seeks more patient cost-sharing (but the legislature wouldn’t raise CHIP premiums) and some provider & druggist fee cuts 

Virginia---a 209(b) state with no risk pool. Its aged/disabled level is 80%, its parent level is 24%/30% if working (2008),  CHIP’s is 200% & ADAP’s is 400%. Gov. Kaine (D) covered the working disabled & started a SPAP for HIV+ Pt. D clients under 300%, but dropped proposals for 100% parent & 300% CHIP levels & subsidized insurance for those under 200%. The legislature (D-Sen; R-House) rejected Kaine’s pilot subsidized insurance plan for those under 200% but he got a foundation to fund it. With a $2.9 billion deficit that’s grown by $1.5 billion--and a caseload grown by 1/3 since 2000-- big Medicaid cuts must now be made. Kaine earlier de-funded a small indigent health program & then most recently a $13 million centralized state Rx-buying program for the mentally ill (which will shift their Rx costs to local health agencies). 

Virgin Islands--its matching rate is far below what states get. Some say its ADAP (with a 400% level) has a waiting list. 

Washington--its risk pool has a supplement open to some, but not all, Medicare patients & a low income premium discount for those under 300%. Its aged/disabled level is about $720 (the SSI/SSP rate), its parent level is 38%/77% if working (2008) & ADAP’s is 300%. Gov. Gregoire & the legislature (both D) passed mental health parity; and made private plans let children stay covered to 25. Facilities evicted 75+ assisted living clients due to low state fees. A $9 billion deficit didn’t stop the CHIP level from rising from 250 to 300%. The state first proposed dropping 40,000 patients from Basic Care (state-subsidized insurance for non-Medicare adults under 200%, with 78,000 already on its waiting list) but then said it could get enough savings by raising premiums & co-pays; cutting General Med. Assistance $190 million (dropping 3,000 more), DSH payments $107 million & nursing home rates $38 million; and slashing druggist, pediatric, HMO & adult day health center fees. It may end adult dentistry & colorectal cancer screening. Legislators are considering bills for a referendum to raise the sales tax by $381 million to avert Medicaid & other health cuts; boost low income clinic subsidies; ease CHIP eligibility; and let over-income children buy into a CHIP-like plan. But ADAP’s formulary was cut. 

West Virginia---has an aged/disabled level of $674/mo (the SSI rate), a parent level of 17%/34% if working (2008) & an ADAP level of 250%. It covers only 4 brand Rx’s/mo (+6 generics). Its risk pool has no Medicare supplement but now is authorized to give low income premium discounts. It denies all adult dental care but extractions; and didn’t properly adopt nursing home & HCB medical admission rules (which still retard access). Gov. Manchin & the legislature (both D) started an Rx aid plan for non-Medicare adults under 200%; and give clients more mental health care & Rx’s to sign personal responsibility pledges. See “Mountain Health…” at www.familiesusa.org  & www.hsc.wvu.edu/wvhealthpolicy .Manchin raised the CHIP level to 250% & may raise child dental fees. A $200 million deficit--plus a FY13 $95 million Medicaid shortfall rising to $169 million in FY14--now bars action on plans Manchin had been considering to widen adult coverage 

Wisconsin---has an aged/disabled level of about $757.78/mo (the SSI/SSP rate), a 200% parent level & a 300% ADAP level. The SPAP has a 240% level & CMS still lets it exclude the disabled. The risk pool has a Medicare supplement & premium discounts for those under $33,000. Gov. Doyle (D) got the legislature (now D) to raise the CHIP (185 to 300%) & parent (185 to 200%) levels, make private plans cover child hearing aids & cochlear implants and give “basic care” (but not brand name Rx’s, home health, LTC or medical equipment) to a projected 54,000 non-Medicare childless adults under 200% (for details & an early evaluation see “Wisconsin’s Badger Care Plus Coverage Expansion” at www.rwjf.org). With a $700 million deficit & “basic care” enrollment already over its funding capacity (plus 20,000 more on a waiting list), he was forced to close enrollment in Oct. & instead propose a non-federal, barebones plan with $50-$100/mo premiums for remaining childless, non-Medicare applicants. He also proposed a $900 million hospital tax to raise hospital rates.  

Wyoming---has no spend down; an aged/disabled level of about $699 (the SSI/SSP rate), a parent level of 40%/54% if working (2008), a CHIP level of 200% & an ADAP level of 332%. Its SPAP covers non-Medicare patients under 100%. The legislature (R) added CHIP mental health, vision & dental care. Gov. Freudenthal (D) added a low income premium discount for those under 250% to the risk pool (which also has a Medicare supplement), proposed developing a cheap, pilot, state-sponsored insurance for the uninsured and even called for freezing CHIP enrollment. High unemployment will  raise state Medicaid costs by at least $100 million next year, so he and the legislature plan to cut most provider fees by $25.6 million, the DD HCB waiver budget by $3.6 million (freezing-in a waiting list) and the state kidney dialysis program by $250;000. The ADAP now has a waiting list and Rx cost-sharing for its patients may also be imposed. Short of funding, a Cheyenne low income clinic is closing and a program providing free and discounted care for low income and uninsured persons at a hospital associated with the Univ. of WY Medical School in Laramie may be curtailed or ended.   

SOURCES AND RESOURCES: 

For the 48 states & DC, 100% of the 2009 federal poverty level (FPL) is $10,830 yearly ($902.50/ mo) for one plus $3740 yearly ($311.67/mo) more for each add’l person; see the Assist. Sec for Plan. & Eval. pages at www.dhhs.gov for AK & HI. In 2008, 100% of the FPL was $10,400/yr ( $866.67/ mo) for one & $3,600/yr ($300/mo) more for each add’l person .The 2009 & 2010 SSI rates (not including state supplementary payments, or SSPs) are $674/mo for 1 person & $1.011 for 2. Email sherry.barber@ssa.gov for “State Asst. Programs for SSI Recips, 1/09”(the latest compilation) on state Medicaid rules for SSI recipients, state supplement (SSP) amounts & state Sec.1616, 1634 & 209(b) arrangements   

See the just-updated  “Side By Side of Major Health Reform Bills and Proposals” at www.kff.org .  

See “Health Care Reform: The Cost of Doing Nothing (State By State Fact Sheets) at www.dpc.senate.gov .  

See the 50 state survey of Medicaid spending, coverage& policy in 2009 & 2010 (Document #7985) at www.kff.org  

 “Using Primary Care..: Est. Impact of..Hlth Ctr Expansion...” at www.gwumc.edu/sphhs/departments/healthpolicy notes that the House reform bill’s $38.8 billion to expand community health centers can serve 20 million more patients and (because of such facilities’ low fees & economies of scale) save $59 billion in federal Medicaid costs over 10 years.    

 “Medicaid Benefits” at http:medicaidbenefits.kff.org/  lists state chiropractor, podiatry, eyeglasses, optometry, hearing aid, hospice, psychologist, prosthetics, home health, medical equip, dental, Rx & OTC drug and phys., occup. & speech therapy coverage, 2003-8; see the “Adult Benefit Chart” at http://www.medicaiddental.org on adult dental coverage. 

See guides on blocking bad state plan amendments at www.healthlaw.org. To ensure plan amendments & waivers get considered & approved by legislatures & not just Governors, see http://www.nachc.com/advocacy/Files/state-policy/model520state520legislationh.pdf & http://www.nachc.com/advocacy/Files/ModelStateLegislation-AppropriationsRiderssr031406_RS-.pdf.    

The “National ADAP Monitoring Report, 2009” at www.kff.org , lists state income & asset  levels in Table XIX and their policies to coordinate with Part D in Table XXVI. The Report also covers state cost sharing rules & medical criteria and/or prior authorization for special or costly drugs. State formularies are listed in a 2nd adjacent document. See “ADAP Watch” at www.NASTAD.org for news of state waiting lists, cost containment measures & state websites   

State Rx co-pay data is in “State Medicaid Drug Reimburse. ” at www.ascp.com . See “Pharm. Benefits [in] State [Medicaid]” at www.npcnow.org on formularies, fees, OTC items, prior auth., prescribing/dispensing limits & co-pays.  

 See www.kff.org  for SPAP & Part D materials and also http://www.ncsl.org/programs/health/SPAPCoordination.htm  Email jcoburn@hdadvocates.org for chart on how drug makers’ Patient Assist. Programs (PAPs) mesh with Pt D. The 6 drug classes excluded by Pt D can be covered by Medicaid; such state coverage is charted at www.medicareadvocacy.org/Part D_ExcludedDrugsbyState.htm (12/1/05 report at “News” icon) 

 See “Individual…Models of LTC’ at www.statehealthfacts.org for state coverage of HCB waivers, home health, personal aides & related care & “Money Follows the Person 101” at www.nsclc.org. Email lsmetanka@nccnhr.org for 2006 state personal needs allowances (PNAs) for SNF & ICF patients and those in SSP-funded board & care homes.  

Email nrelave@aphsa.org to subscribe for free to “Working For Tomorrow”, a monthly e- newsletter reporting on benefits (including Medicaid and Medicare) for the disabled and programs to promote their employment.   

See www.naschip.org on state risk pools & order “Comprehensive Health Ins. for High Risk Individuals: A State-by-State Analysis”[2008-09] on funding, eligibility, benefits, Medicare supplements, premiums & low income discounts 

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.. have epilepsy and/or hemophilia aid programs too 

See ”From CANN ” in “Other Organizations’ Materials” under ”Library” at www.healthlaw.org for “ Painless Ways To Deal With..Medicaid Budget Shortfalls” to avoid eligibility & benefits cuts;  “State..Aged/Disabled ... Income Levels” &  “State…Parent..Income Levels”; a health/Medicaid  “Glossary”;  and  “2009 VA Health…Benefits”