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 4 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, and they had to cut ADAP’s formulary. The legislature also cut Medicaid’s drug budget by $30 million, but he restored $7 million of that to retain 4 brand & uncapped generics drug coverage per month. It may again need an ADAP waiting list.

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 4 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, and they had to cut ADAP’s formulary. The legislature also cut Medicaid’s drug budget by $30 million, but he restored $7 million of that to retain 4 brand & uncapped generics drug coverage per month. It may again need an ADAP waiting list.

Arizona--covers parents 100%/106% if working and aged & disabled adults under 100%.  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 and cut MD fees & personal care funds. With a    budget short billions, Gov Brewer (R) cut ADAP’s formulary, mental health funds & home care, ended hospice care & & kept a CHIP freeze that’s cut enrollment to 16,000-- with a  waiting list of 100,000. She started new & raised existing co-pays (but the 9^th Circ. uphelda US Dist Ct. order barring co-pays ranging from $4 to $30), will end the spend down 10/1, dropped coverage of phys icals, podiatry, most dentistry, dentures, transplants (she later partly relented), medical equip, insulin pumps, hearing aids, cochlear implants & some prostheses. HHS said it can’t stop expiration of a waiver covering 280,000 childless, non-dis- abled adults. (Yet coverage of anyone under 100% was mandated by a state  referendum law & a 2nd referendum amen- ded AZ’ constitution to ban legislative flouting of referenda-passed laws; so advocates sued to bar the cut in the state Sup Ct & Maricopa Co. Ct—but at first rebuffed by both--they again appealed to the state Sup. Ct ). Brewer will close enroll- ment & let present clients’ coverage 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 pa-tients, but 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%. 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’s covered to 6/mo, MD visits to 7/ yr & MD fees 10%; charging $3-$5 Rx, $50 ER, $5 MD & $100- $200 hospital co-pays  & ending adult day health care. A $300 million LA Co Health Dpt. deficit may cut patients served 1/4 to 1/2. Courts barred ending adult podiatry, chiropractic & dentistry without CMS consent. Brown cut $390 million from CHIP & funds for home, mental health  & DD care; is forcing the aged & disabled into managed care; added $77 million to ADAP; is starting a Health Exchange; is adding childless, non-disabled legal residents up to 200% to US-matched Medicaid (see http://www.kff.org/medicaid/8197.cfm  & email adonnelly @projectinform.org for more); but plans to cut Medicaid payments 10%, which is being litigated up to the US Supreme Ct 

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%. The risk pool has low income premium discounts for those below $50,000 & Medicare supplements. The state set up a formulary, made health plans cover PTSD, anorexia, substance abuse & colorectal screening. but cut ADAP’s formulary. The old legislature (D) passed a $600 million hospital tax for Medic-aid, 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 now covers parents, but the income level for for childless, non- dis-abled adults was just cut from 100% to only 10%--with a cap of only 10,000 clients); applied the mini-COBRA law to small firms; raised CHIP’s level from 205 to 250% & widened its psychiatric care; offered Medicaid to the working dis-abled; covered legal aliens; set a 300% level for nursing home & HCB waivers (with liberal HCB, personal aide & patient autonomy features). Advocates say the 300% FOA level is too low to cover enough disabled children, that premiums are too high & say the state rations how many can be covered. The state cut funds for DD & disabled clients’ employment, transport & personal aide pay, but raised the pregnant woman level from 133 to 185%. Gov. Hickenlooper & the Senate (both D) campaigned for more health expansion, but instead made a big cut., There’s a new 1-vote 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/mo 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. 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 offered hospice care to all Medicaid patients. The legislature (D) covered the working disabled. Rell wanted to force patients into HMOs to fund a skimpy “Charter Oak” insurance plan for parents under 306% & other adults under 310%. Its premiums rose 72% since 1/10 (with a another big raise in 9/11; subsidies were also cut, as they were in 2010). It has big co-pays, limited psychiatric care, low caps on Rx’s, medical equip & total yearly costs & a $1 million lifetime cap. CMS provides matching to give Medicaid to childless, non-disabled adults under 56% who were on state Gen Med Asst (keeping its $150/mo earnings disregard).  The state extended COBRA to 30 mos, and raised QMB’s single income level to $1779.68/ /mo, SLMB’s to $1,961.28 & QI’s to $2091.67 (giving them full Pt D Extra Help too, which allowed the state to exclude them from the SPAP—while it still offers SPAP coverage to  the disabled in the 2 yr Medicare waiting period). Gov Malloy (D) is moving 2,200 from nursing homes into home or HCB care and canceling CHIP & Charter Oak managed care contracts He cut respite; adult dental & vision benefits and low income clinic funding $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 QMB’s level to 300% & dropped its asset test (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 only-recently-raised MD fees for dual eligibles & cut home care & funds for the disabled’s personal aides. Mayor Gray (D) extended Medicaid to childless, non-disabled legal residents 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 & adding other patients only later; see http://tinyurl.com/FloridaCHAIN) even though its request  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 ref-orm state risk pool has a Medi-care 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 waiting period. The parent level is 20%/59% wkg (‘11).. The state covers dentures (but little other adult dentistry) & hearing aids. Ex-Gov Crist made private plans cover autism care & fostered cheap policies for the uninsured ( 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 cheap, but lean, “Miami-Dade Blue” policies with no brand name Rx benefit. Crist dropped hospice care and 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 refused a $37 million extra US grant to fund more HCB waiver slots over costlier nursing homes. Crist raised cig-arette 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 3,908 (even though 5,403 more 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 public low income clinics. Scott made a 15% cut in funds for DD facilities and 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; en-

ded 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 care for all but 22 of  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 1,778); and  proposed privatiz-ing some mental health care. With a $680 million Medicaid FY 12-13 shortfall, Gov. Deal (R) proposed even more cuts (i.e., ending adult podiatry, vision & emergency dentistry). but the House voted to retain those 3. He still wants to raise adult O/P care co- pays to 15%. their I/P hosp co-pays by 400% and even impose cost sharing on children for the 1st 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 long-time health expansion advocate-- 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 a year, 10 hospital days a year and 3 outpatient surgeries a year.

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; did 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 40). 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 were to be  be cut from 235% to 200%--and their co-pays 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). 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 Chicago 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% & also other taxes; required better income verification by applicants; tightened a generics preference rule (and now requires pre-authorization for 17 costly psychiatric drugs), is forcing 1/2 of clients (mostly non-disabled par-ents & children) into managed care and 40,000 aged & disabled in Chicago’s suburbs into it too; and cut Medicaid Rx fees $42 million.. He denied CHIP to children over 300%; hopes to save $400 million more with case management for the aged & disabled (38,000 are on HCB waiting lists); found $30 million more for low income clinics; and gave ADAP enough money to serve 4,500 more clients (but with a $2,000/mo patient cost cap). A $1.5 million HIV funding cut means rising ADAP needs can’t be met: so the level for new patients was cut from 500 to 300% (grandfathering- in current clients).

Indiana--this 209(b) state’s SPAP (for which a state law passed in 6/11 now seeks US matching to partly fund it—but still as an aged-only waiver) covers those under 150% but 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 considering a once-every-5-years eyeglasses replacing 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 bel-ow 200% & even has 34,000 slots for the childless, non-disabled under 65 (with 52,000 more of them 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 its HSA requirement s is allowed). Waiver coverage is via HMOs; has few co-pays, but has 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 & other provider fees 5%. The State Supreme Ct  rejected a suit to make the state consider more possible impairments in Medicaid disability de-terrminations. Budget cuts will end or limit adult dental, vision, chiropractic & podiatry coverage. Daniels tightened 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 cov- erage buy into CHIP dental benefits. The hospitals proposed taxing themselves $40 million to attract added US matching funds to raise their rates & meet other costs. ADAP program costs were capped on 9/15/10, 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, rais-ing co-pays & requiring pre-authorization for more types of care) and the state Senate (still D) even agreed to his budget! 

Kansas---this Title XVI state has an aged/disabled level of $674/mo (SSI’s rate), a parent level of 26%/32% wkg (‘11), and 200% CHIP & a 300% ADAP level. Its GOP legislature covered the wkg disabled, offered 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 funding for the aged & disabled; put 6,000 more on waiting lists for HCB & home care; cut MD fees & disabled cli-ents’ caregivers’ pay, ended welfare for 1,500 awaiting SSA disability awards; denied dentistry to poor women; raised CHIP premiums to $20/mo; and froze admissions to state mental hospitals. Gov. Brownback (R) wants even more health cuts: He ordered Aging Dpt worker costs slashed 1/4, cut mental health funds $25 million, cut the community mental health center budget, proposed ending mental health services for 850 families with troubled children & told his Lt. Gov. to plan Medicaid cuts of $200 to $400 million yearly (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 funds for blind children from $80,000 to $10,000/yr, li-mited occu, phys & speech therapy, x-rays & MRIs; and raised co-pays. Gov Beshear (D) faces a Medicaid/CHIP deficit      of up to $500 million, yet still enrolled 22,000 more children in CHIP & dropped its $20/mo premium. ADAP has co-pays & its formulary was cut. After the Senate (R) and the House (D) spurned his budget for a GOP plan, he successfully line-item vetoed their bill. Now he is implementing his own Medicaid budget plan to save $375 million in state funds by mov-ing 560,000 of 820,000 non-L’ville area clients into 3 HMOs  by 10/11 (170,000 in the L’ville area are already in an HMO) 

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  $30 million /yr for clinic funding when US funds weren’t renewed & CMS even let him spend $97.3 million in US Medicaid hosp 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 & disab-led patients. He plans to put almost all patients into 5 CCOs (but the legislature is considering terminating these contracts on 12/31/14).  US matching fell $700 million & 2012’s deficit rose to $1.5 billion. FEMA will pay $478 million to rebuild the N. O. Charity Hosp & the state will add $300 million but it must find $70-$100 million/yr more to run it  Jindal wants a $62 million cut for LSU’s Hospitals even though he already lacks enough funds to run 4 to 6 LSU & Charity Hospitals. ADAP’s $11.7 million deficit required shifting $2 million of other HIV funds to it, but there’s still a waiting list of 929.

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 waiv-er); 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. QMB’s income level is 150%, SLMB’s, 170% & QI’s, 185%. The state raised cost-sharing for those over 150%, and cut podiatry care & provider fees .Gov LePage & the legis-lature (both R) at first joined Democrats to pay hospitals $70 million in past-due bills (but then a later re-audit showed that, in fact, the hospitals had been overpaid  that same amount) & even to add $73 million more to the Medicaid budget (for which even more may soon be needed because CMS auditors now suspect the state over-claimed $150 million in past US matching). LePage plans to drop 16,000-–even with 14,000 more on its waiting list—of the childless, non-disabled  from the waiver (he says it’s a voluntary state add-on that needs no HHS approval to be ended & isn’t subject to the US’ maintenance-of-effort laws), 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.  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 and 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 match-ing  He again cut providers’, HMOs’, HCB programs’ & the disabled’s personal aide fees. 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 match-ing. 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 & for other costs. He’s raising child dental fees, carving child dentistry out of HMO contracts & made hospitals give free care to those under 150%. The legislature called for a $40 million Medicaid budget cut. 

Massachusetts---In 2006, ex-Gov. Romney (R) & the legislature (D) required all adults to have insurance, subsidized it for those under 300% & boosted the CHIP level from 200 to 300% (a state program started about 1990 offers CHIP-like coverage to children under 400%). In 1997 the the parent & childless disabled Medicaid levels rose to 133% but the child-dless aged level is still 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 & Medicaid MD visit & Rx co-pays from $2 to $3; raised SPAP cost-sharing; froze MD & hospital fees; and cut public health program funds. The legislature got him to delay cuts in adult day health programs until at least 12/11; grandfathered-in undocumented aliens getting insur-ance subsidies & Medicaid since before 8/09 to limited benefits; and reduced adults’ Medicaid & subsidized insurance dental care to emergency & preventive services and cut covered hospital days to 20/yr. To better control costs, he wants to shift to Accountable Care Organizations (ACOs) to pay for wellness & treatment results rather than fee-for-service rates that now drive costs too high. A legislative reform panel is expected to develop its own payment reform bill by late 2011. CMS approved a waiver add-on to give the Cambridge Health Alliance $216 million & $270 million to other hospitals. 

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-lts 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, short of funds,  Flint’s Genessee  Co.now has a 2 mo waiting period & may close enrollment). With a $480 million 2012 deficit, the then D, now R) House & Senate (still R) briefly ended adult vision care, but then, 2 years ago, restored adult dental, vision & podiatry (but not hearing aid or chiropractic) care and avoided MD, hospital & most mental health cuts. Gov. Snyder (R) pledged to make no eligibility or regular provider fee cuts per se; but cut teaching hospitals $67 million, general Medicaid agency costs $21 million, began moving dual eligibles into HMOs and, say advocates, cut home chore aid so much as to  undermine de-institutionalization efforts (costing much more in resulting, higher nursing home bills) and is drop-ping 11,000 families from TANF on 10/1/11 (claiming that they’ll seamlessly be kept on food stamps & Medicaid). The US- funded, state-run risk pool cut its premiums ($103 to $415/mo by age band), but to do so raised deductibles to $3,000 & co-pays to $10, $20, $50 & $100. The state’s considering replacing an HMO tax—which CMS now says is imp-roper--with a low tax on 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 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, the state raised Medicaid , CHIP & MinnesotaCare (state-subsidized insurance for parents under 275% & childless, non-disabled adults below 250%) premiums & co-pays and den-ied 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 speech & oc-cu therapy, audiology & adult dentistry. Gov Dayton (D) expanded US-matched Medicaid to cover previously  state-funded Gen. Med. Assist.(GMA) patients under 75%  He & the new legislature (R) compromised: He dropped proposed “mil-lionaire”, hospital & nursing home taxes & accepted  repeal of provider taxes that had been funding Minnesota Care. They funded the 100,000+ GMA & Minnesota Care clients added to Medicaid, dropped their plan to substitute $240  monthly vouchers 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 & bigger co-pays; proposed a 7% mental health cut, lower mental health center subsidies and closing 4 mental hospitals & 15 ment-al crisis centers. Some disabled children’s parents say the state 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. 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); ended adult dental coverage; raised CHIP premiums; denied CHIP to those whose job plans cost under 5% of  income; raised & more strictly enforced co-pays; but kept the ADAP & CHIP levels at 300% & raised the SPAP level (it covers only those already on Medicare) to 150%. Blue Cross & a foun-dation subsidize insurance for KC-area families under $30,000 The state pays “premium support” for clients’ job plan premiums but denies them full secondary Medicaid; restored hospice & wkg disabled coverage (which covers only those with very low SSDI checks); gives birth control & screenings to women under 185%; restored adult vision (except  for the aged in nursing homes), hearing aid & podiatry 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). Growing costs made Gov Nixon (D)  drop plans to restore the 100% aged/disabled level & boost outreach. He sought hospital rate cuts of $139 million & $32 mil-lion in MD & DDS fees and mental health & public clinic funding. The ADAP director cut its formulary in Jan. ’10  to cover only anti-retrovirals & Rx’s for opportunistic  infections--but restored the full formulary in Nov. ‘10. The state made private plans cover some autism care. CMS said the state is wrongly limiting 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. 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 (R) ended a CHIP waiting list (yet ADAP has one of 13);  raised the family asset level; set up a SPAP for aged (but not disabled) Medicare patients under 200%; widened CHIP dental & preventive care; made private plans cover vaccinations & well-child care to age 7; and raised  CHIP’s level to 250%, but sign-ups are slow Schweitzer agreed to the legislature’s 6% provider fee cut  (it also voted to “study privatizing Medicaid administration”). 

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 supple-ment 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 payments 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 formul-ary was cut too. But the legislature is now reconsidering its exclusion of pregnant aliens (even legal ones) from Medicaid after over 1,500 untreated cases resulted in needless & costly premature births or stillborns. It did widen school health ser-vices. Heineman proposed denying Medicaid to clients who don’t meet 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 lev-el 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. The state capped CHIP dental care 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 & attendant payments for the disabled; non-emergency trans-port, hospital neonatal, HCB waiver and pediatric specialist fees. It 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 (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 instead 

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 (R) shifted nursing home costs to counties, but ended a DD care waiting list—yet will make more cuts in provider fees.  The  legisla-ture voted to move more patients into HMOs; slashed $1 million to fund case managers for the aged & disabled in board & care group homes; and even diverted to other budget accounts $230 million in  bed taxes that  yielded sufficient funds to attract enough added US matching to meet hospital shortfalls due to uncompensated care & too-low Medicaid rates 

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 likely will--or has--veto[ed] 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 legislature earlier raised the parent level to 200% & ended CHIP premiums for those below 200%.  The state cut hospital charity & teaching funds, raised SPAP co-pays & cut its formulary. Christie sought to drop coverage of legal ali-ens, township indigent care funding & expanded overage of parents (but he later relented on the parent cut). The legis-lature opposes his $3 adult daycare co-pay proposal and ending state Part D wraparound & co-pay aid. He still rejects 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 second comprehensive” waiver to “save” $300 million (Google “New Jersey Concept Paper” for details; but note that any parent level cuts have been drop-ped). He plans $240 million in savings by forcing the rest of the aged & disabled (many are still in fee-for-service cover-age) into managed care plans (including even their Rx, home health, adult day health care & personal attendant services) and cuts of $8 million each to ADAP & women’s health---plus $9 million in mental health & $5 million in legal aid cuts 

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 Medicaid shortfall of  $300 million+, the state may end adult dental, vis-ion, 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) 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. And the Medicaid agency discovered a shortage of $100 million to pay due Medicaid bills & asked the legislature to make it up 

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); 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. Even with a $12+ billion 2012 deficit, ex-Gov. Paterson (D) started a discount Rx plan for the disabled, raised all Medicaid asset lev-els ($13,050 for 1, $19,200 for 2, etc), ended MSP & SPAP asset tests and extended COBRA to 36 mos. But he signed a bill with $775 million in health cuts, aimed at saving $300 million more in each future year. 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 dent-al program, cut its HIV services $17 million &de-funded a health insurance advocacy office. NYC’s Mayor wants to cut 182 school nurse jobs. Gov Cuomo (D) & the legislature passed $1 to $2.8 billion in Medicaid & EPIC cuts, will force all Medicaid patients--even nursing home & HCB waiver patients, if CMS agrees--into HMOs; and tightened drug formularies for some diagnoses.  A summary of the many, very complex cuts is in “Medicaid & EPIC Cutbacks.” at http://www.selfhelp.net/  And mind-boggling, very detailed sets of charts set forth the new income & asset eligibility levels & 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. 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 limited mental health parity. It has a pre-health reform state risk pool that excludes Medicare patients, requires pre-authorization & has a $250 co-pay for “specialty” Rx’s & a $100,000/yr out-of-pocket cap but has low income premium discounts.  Gov Perdue (D) set up a preferred Rx list, later adding some psychiatric Rx’s to it); proposed closing 50 mental hosp beds & cutting MD, hosp, personal aide, maternal care & community mental health funds. The state cut audiology & hospice care and limits speech, occu & phys therapy visits to 3/yr; ADAP was cut $3 million, has a formulary limiting coverage to Tier 1 Rx’s & an income level cut from 300 to 125%. The budget ends Med-icaid’s HIV case manager program & coverage of community-based rehab care and many child dental X-rays & sealants; limits breast surgery; and requires prior approval of X-rays, MRIs, MRAs, PET scans, ultra-sounds & even some EPSDT services. The state later found $14.1 million more for ADAP, cutting its waiting list to “only” 356 (but it may now require pre-authorization for Medicaid’s HIV Rx’s). The hospitals got the legislature to tax them $200 million/yr to attract more US matching to raise their rates (even though they may have earlier over-charged Medicaid $50 million+) & meet other health costs; but, with a $358 million budget cut, the state will limit or end coverage of adult insulin, eyeglasses, dentistry, podiatry & chiropractic care. It seeks a waiver to give personal care services to board & care residents; and state plan am-endments to better co-ordinate mental & primary care, pay coordinators incentives to cut hospital readmissions & ER vis-its, and consolidate community programs for children & disabled adults (including mental health & HIV care) into fuller coordinated care. CMS now says that the state’s placement of thousands of de-institutionalized mentally ill in board & care homes is improper and their costs are un-matchable—creating still another huge state Medicaid funding crisis. 

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 cov-ered 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%, a 200% CHIP level, but cut the ADAP level from 500 to 300% (briefly triggering a waiting list & possibly denying eligibility to 861 more with CD4 counts over 500 if those counts haven’t ever fallen below 200). 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 only $589/mo (the US’ very lowest). The state covered disabled children under 500% via the FOA; cut nursing home fees (but the legislature then partially restored them & boosted home care benefits); cut Rx fees & community mental health funds; and required Rx co- pays & a generics preference rule; but restored adult dental & vision care. It told nursing homes to pay for their own patients’ phys therapy, wheelchairs & medical equipment. The state moved 592 from waiting lists into HCB waivers & imposed $718 million in fees on hospitals to be used to get more mat-ching & raise rates; and applied mini-COBRA rights to small firms. Gov Kasich & the legislature (both R) plan a $1.4 bil-lion 2 yr Medicaid cut: moving disabled children, the mentally ill, nursing home & HCB waiver patients, dual eligibles & finally all aged & disabled into managed care; cutting nursing home fees $360 to $470 million (they claim they’ll spend $55.6 million more on HCB waivers, yet plan deep cuts in the total FY ’12 LTC budget); hospital rates $478 million, ma-naged care $58 million & psychiatric care $135 million. He found $5 million more for ADAP, cutting its waiting list to 0..

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 doesn’t cover hospices, but did cover the breast & cervical cancer & wkg disabled groups & sub-sidized insurance for students, the unemployed & small firm workers under 200%. The legislature (R) later cut the insur-ance premiums & eased eligibility but also cut its benefits; covers assisted living & raised the CHIP level from 185 to 300%.  Gov Fallin (R) may drop pregnant women’s dentistry, durable medical equip & nebulizors; 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 & ended speech, occu & phys therapy benefits.  

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 subsidized insurance for non-Medicare adults (with enrollment closed) & 200% for ADAP. An anti-tax referendum cut el-igibility & 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%. He signed a bill to use capitated “coordinated care organizations”, which 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 & the new legislature (both R) chose to limit adult dentistry (e.g., dropping root can-al coverage) & Rx’s to 6/mo  (with an exception process}, impose co-pays on disabled children  over 200% , cut mental & women’s health care & ended the Adult Basic program--even with 40,000 patients on it & 496,000 more on its waiting list. But case record reviews suggest that nearly 1/2 of those dropped may be eligible for Medicaid, according to Commun-ity Legal Services of Phila. 2012’s deficit is $4 billion. Phila. city clinics now must bill $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 terminated, and still-uncovered, AdultBasic  patients 

Rhode Island---has these income levels: aged/disabled, 100%, parents, 175% (181% wkg), CHIP, 250% & ADAP, 200%. 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 & capsfuture US funds. The legislature (D) raised adult daycare co-pays; dropped coverage of legal alien children.& ended child- care workers’ insurance. Gov. Chaffee (I) is expected to have a moderate health policy & may attempt to end the waiver.

South Carolina---has no spend down. Its aged/disabled level is 100% & its parent levels are 50%/93% if wkg (‘11). It cut ADAP’s level to 300%. Its risk pool has a Medicare supplement but no low income premium discount. The legislature
(R) limited Rx’s to 4/mo & raised CHIP’s level to 200%. The SPAP has a 200% level but excludes the disabled. The state cut mental health benefits, closed an HIV program to new clients & slashed home health, hospital & nursing home fees;
passed private plan mental health parity; 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 420), cut home, personal aide & HCB care (the last 3 face court suits) & covered Rx’s from 8 to 7/mo, required a generics “”fail first” rule for mental health, oncology & HIV patients before they can get brand Rx’s & de-funded cancer screening. Gov. Haley (R) planned to end hospice coverage (but relented) but did cut speech & occu therapy sessions from 225 to 75/yr. With a $200 million deficit rising to $1 billion she hopes to save $200 million with ” public-private care provider partnerships”, $18.5 million by reducing low weight births, favoring HCB care over nursing homes, ending adult vision & dental care, raising co-pays & reducing C-sections & hospital readmissions. She will cut hospital, MD & DDS rates by $300 million

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. The state re-opened its spend down program--limited to the first 2,500 callers--starting 9/12/11 (see www.tnjustice.org for details)   

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 Medi-caid home health & ended adult chiropractic & podiatry care; are moving more  patients into HMOs; but restored Medic-aid vision & hearing aid coverage and CHIP dentistry (Medicaid covers limited adult dentistry); and required some mental health parity in private plans. I has a SPAP for HIV clients. A court required improved EPSDT & child health with higher MD & DDS fees (yet Perry still plans 10% rate cuts). The 2011-12 deficit is $27 billion. The legislature cut the Children with Special Health Needs program & a cystic fibrosis aid program for all ages by $3.5 million (even with 950 children on a waiting list); wouldn’t fund 13,000 needed HCB waiver slots or $19 million that ADAP needs and even authorized cutting its income level from 200 to 125%  if necessary. It left $4.8 billion of the Medicaid budget unfunded after early 2013, when it must either find more money or make big Medicaid cuts—and even authorized transferring $19 million from its skimpy budget to ADAP’s even  worse budget needs. The state now seeks a waiver to capitate Rx benefits via managed care—and, if approved, it will drop its prior monthly 3 Rx limit & even fund additional low income clinics. 

Utah—is a Title XVI state with a risk pool that has a low income premium discount, but no Medicare supplement. Its ag-ed/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—but not I/P--care, with big co-pays, to non-Medicare adults (even if childless & non-disabled) under 150%. The legislature (R) ended coverage of  podiatry, audiology, speech therapy, chiropractic, some wheelchairs, and adult eyeglasses & dentistry; cut hospital & DDS fees 25%; but subsidizes insurance for workers under 150% in small firms. Gov. Herbert (R) restored child & pregnant women’s dental care & some phys & occu therapy—but then cut DDS fees again (without CMS consent); and cut its ADAP formulary & income level to 250% (dropping 52 clients) & closed enrollment to new patients--so again there’s an ADAP waiting list (of 59 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 signed a bill to force Medicaid patients to “work” for their benefits, and he & key legislators  seek a waiver to cut eligibility, run Medi-aid with ACOs (some advocates say they’re sub-par, “gussied up” HMOs),  raise co-pays & charge $40/mo  premiums 

Vermont—Its levels are: aged/disabled (2 zones) 101% & 110%; parents, 185%/191% if working (’11); childless, non-disabled adults, 150% /160% if wkg; CHIP, 300%; ADAP, 200% and the SPAP, 175%. There are no MSP asset tests. The state subsidizes insurance for others under 300%. Dentures aren’t covered & there’s a $495/yr dental care cost cap per ad-ult. A waiver, in return for more US funds, moves patients into HMOs and favors home & HCB care over nursing homes--but also caps future US matching funds. The 2011 health & welfare shortfall was $53 million. Ex-Gov. Douglas (R) pro-mised not to cut eligibility (even signing a bill requiring more private plan autism coverage), yet raised SPAP co-pays. Gov. Shumlin & the legislature (both D) enacted a law to establish a state universal coverage health insurance plan. 

Virginia---this 209(b) state’s parent level is 25/31% if working (‘11), CHIP’s is 175% & ADAP’s is 400%. It covers the wkg disabled. Gov McDonnell & the House (both R) ignored gentler Senate (D) approaches 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 children) and the aged/disabled level from 80 to 75%. Some mental health, Hep C & a few other Rx’s were cut from ADAP’s formulary & it closed enrollment (except to pregnant women, children & those being treated for opportunistic infections). The ADAP waiting list is 3.010. A SPAP covers premiums & cost-sharing for HIV+ Pt D clients under 400%. The legislature over-rode McDonnell’s veto to make large firms’ health plans cover some autism care   

Washington--its risk pool has a supplement open to some, but not all, on Medicare. Its aged/disabled level is $720 (the SSI/SSP rate), its parent level is 37%/74% if wkg (‘11) & ADAP’s remains 300%.  Gov. Gregoire & the legislature (both D) passed mental health parity. Budget cuts forced her to end CHIP for 27,000 undocumented children. The state raised BasicHealth (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; cut DSH payments & nursing home fees; and limited non-emergent ER visits, Rx, DME, imaging, denture, diabetic items, personal aide, home care, adult daycare, 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. Three non-HIV Rx’s were rem-oved from ADAP’s formulary & cost-sharing is required of those over 100% or not on Medicare or Medicaid. The state sponsors discounted, unsubsidized insurance. A Medicaid waiver pays matching for BasicHealth & “Disability Lifeline”  medical assistance, but the state cut 17,000 off  BasicHealth for being illegals, over  65, or having income over 133%  The legislature cut Medicaid’s provider pay budget $4 billion, over hospital & home care worker opposition. Gregoire signed a nursing home tax, with proceeds to be used to attract more matching to bolster their rates & other costs; and seeks a CMS waiver to use a Medicaid “individual per cap payment”: See http://www.wsha.org/files/83/StatesSubmissiontoCMMI.pdf  

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 state risk pool has no Medicare supplement but low inc-ome premium discounts have been authorized. It denies all adult dental care but extractions & emergencies & didn’t prop-erly adopt nursing home & HCB medical admission rules (which still impede access). The legislature (D) started an Rx aid plan (via low income clinics) for non-Medicare adults under 200%. CMS is trying, over state objections, to halt a wai-ver that offers clients more mental health care & Rx’s--but only if they sign “personal responsibility” pledges. It had plan-ned to put the disabled, parents & children into managed care that some say cuts care access. Gov Tomblin (D) & the legi-slature raised the CHIP level to 300% & passed a hospital tax with proceeds to be used to attract more Medicaid matching    

Wisconsin---has an aged/disabled level of $757.78/mo (the SSI/SSP rate), a 300% ADAP level & a 240% SPAP level  (it 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 (to 300%) & parent (to 200%) levels and started a “Basic Care” plan for non-Medicare childless adults under 200%, but its caseload soon outgrew funding.  Gov Walker & the new legislature (both R) plan $3 billion in Medicaid cuts, including dropping the 67,000 already on Basic Care. He’s begun dropping the  67.000, wants to freeze enrollment of the aged & disabled and in a “Family Care” nursing home alternative program & some other aged & disabled programs, cut the parent level to 133%, impose more & higher co-pays and “adjust” pay-ments for kidney care & dialysis and for druggists’ fees. Yet even GOP legislators spurned his plan to cut SPAP coverage  

Wyoming--has no spend down, an aged/disabled level of $699 (the SSI/SSP rate), a parent level of 39%/52% 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). The state planned 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 its waiting list is still 0) & client cost-sharing was required. Gov Mead (R) plans more cuts. 

SOURCES AND RESOURCES:

 Email sherry.barber@ssa.gov for “State Asst. Programs For SSI Recips., 1/10” (the latest update) on state Medicaid eligibility rules for SSI & SSP recipients, state SSP amounts and state Section 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 Asst Sec. for Plan.  & Eval.  pages at www.dhhs.gov  for earlier yrs’ FPLs and AK’s & HI’s separate FPLs. The 2011 SSI rates (not including any state supplements, or SSPs) are $674/ mo for 1& $1,011/ mo 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” 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)  at www.kff.org . 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 pa-tients &  states’ tiny share of their costs starting in 2014 (0% to 10%). See under “publications” at www.ppic.org  “Expanding MediCal;, Profiles of Potential New Users” (8/11), questioning whether previously-uncovered new eligibles will cost any more than non-disabled parents; also Google “Health Service Among the Previously Unin-sured”, in Health Economics (8/24/11), for  roughly similar findings for the uninsured who get  Medicare at age 65.

 “The OR Health Experiment..”(7/7/11) at www.nber.org finds that, among those seeking Medicaid, a comparison of those who get it vs. those who don’t shows those who do get it 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 and “Ten Considerations for States in Linking Medicaid and the Health Benefit Exchanges” at www.chcs.org    

The PPACA “Maximiz[es].. [Primary MD].. Medicaid Rates to Medicare Levels [to get more of them to take Med-icaid patients]..” & “Leveraging the Medicaid Primary Care Rate Increase” (both at www.chcs.org). They,note that the US will pay 100% of added state fee costs in 2014–19. New HHS rules make later state provider pay cuts harder, & more difficult (Fed. Reg., 5/ 5/11); see “NHeLP Breaks Down Crucial Provider 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 therapy coverage. 

The “2011 National ADAP Monitoring Report (Module 1)” at www.nastad.org lists state income & asset eligibility levels in Table 13, application procedures in Table 14 & any prior authorization rules for special or costly drugs in Table 15.  Its “(Module 2)” has a “Glossary” and charts & tables on states’ coverage of often-co-morbid Hepatitis B & C  Rx’s and care. State ADAP formu-aries weren’t compiled in this year’s ”Report” but procedures to get costly or unusual Rx’s are cited . See the “ADAP Watch” at www.nastad.org  on state waiting lists. For current &back issues of the “ADAP Pill Box” see 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 over 70%  of its  patients are already enrolled—often mandatorily--in private managed care plans (so far mostly non-disabled parents & children); but most states now plan to enroll (again, often mandatorily) the previously mostly-exempt aged & disabled too ). See “CA’s Shift to Managed Care Doesn’t Save [Costs] or Improve.. Outcomes ..” (10/05), finding it raises costs 17% over fee-for-service at www.rwjf.org under “pubs. & research”; a summary of cost studies in “Managed Care Explained” (5/31//11) at www.stateline.org, “Assessing.. Financial Health of Med. Managed Care & [Its]..Quality” at www.cmwf.org, “The Evolution of Managed Care in Medicaid” (6/11) at www.macpac.gov . “A Profile of Medicaid Managed Care..in 2010:..A 50 State Survey” at www.kff.org (doc. # 8220) & “Has...Shift to Managed Care [Cut].. [Expenses]..?” at  www.nber.org saying savings depend on states’ baseline fees). For a critique of Medicaid HMO failings, quality, low fees & ways to improve them, see 7/27/11 editorial at www.staradvertiser.com 

“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. and “New  Lewin/ Optuminsight Whitepaper on the Effects of the PPACA 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. For a  thorough overview of state long term care programs,  policies & performance, see the AARP’s www.longtermscorecard.org  (9/11).

 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. But see State Med. Dir. Ltr. # 11-009 of 8/15/11 at www.cms.gov , saying states can change HCB waivers--or even discontinue expiring waivers--if their eligibility changes (very narrowly construed) don’t violate the PPACA’s maintenance of effort (MOE) requirements.     

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 federal health reform-funded  pools are state- or federally-run ; the latter’s premiums & cost-sharing are surprisingly 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/ . The FL, MI, NJ & TX health depts. also have epilepsy and/or hemophilia assistance programs. 

See ”From CANN ” in “Other Organizations’ Materials”  under ”Medicaid” below “Issues” at www.healthlaw.org for a Medicaid, health & welfare “Glossary”,  “Ways To Stretch ADAP Budgets” & an archive of many past Medicaid Watch issues. Also see “Creative Financing” below “Medicaid Defense” under “Issues” at that site for a “Medicaid Maximization Primer” on fiscal strategies for states to increase US Medicaid matching for state/local health expenses & a “Medicaid Cost Containment” paper on other ways to save funds without eligibility, services or provider pay cuts. 

See the “Friday Updates” & the “State Medicaid Reform Tracker” monthly (for state-by-state reports on a wide range of mostly non-eligibility Medicaid news) at www.NASUAD.org  and  http://www.statereforum.org/states on state health reform activities 

The National Health Law Program (NHeLP) has a summary of cost sharing studies which show that increasing low income patients’ cost sharing in health plans always & inevitably prevents or deters their access to necessary medical care. See http://healthlaw.org/images/stories/medicaiddefense/2011_08_02_NheLP%20Cost%20Sharing%20Summary.pdf.   

CMS, HHS & the IRS, respectively, each  issued proposed regulations on state eligibility & enrollment for Medicaid; Exchange health insurance policies (with income-based subsidies); and small businesses’ access to, and tax credits for, state Exchange-based employee group policies on Aug. 17, 2011 in the Federal Register (www.FederalRegister.gov ) . For an excellent, clear blog summary of them see: http://healthaffairs.org/blog/2011/08/13/implementing-health-reform-medicaid-and-exchange-eligibility-determinations/. More information about the proposed rules is at www.healthcare.gov: ·         

Overview:  www.HealthCare.gov/news/factsheets/exchanges08122011a.html

·          Medicaid Eligibility:  www.HealthCare.gov/news/factsheets/exchanges08122011c.html

·          Access to Coverage for Consumers & Small Businesses:
     www.HealthCare.gov/news/factsheets/exchanges08122011b.html

Health Insurance Premium Tax Credit:  www.treasury.gov/press-center/Documents/36BFactSheet.PDF 

The Consumer Operated and Oriented Plan (Co-Op) Proposed Rule (comments were due September 16th) was published in the Federal Register [Vol. 76, No. 139, pp. 43237-43250] on 7/20/11).