January 08, 2019
Rachel Gershon, JD, MPH Senior Associate, Health Law & Policy
State Medicaid programs vary
substantially from one another. For members, researchers, policymakers,
and advocates trying to decipher a state’s Medicaid program, this
variation can be a source of frustration, because the details of this variation
can be hard to locate.
Medicaid is a public health insurance
program for low-income Americans administered by states. When running
their Medicaid programs, states must follow federal Medicaid law and other
requirements. Federal Medicaid law is quite detailed and prescriptive,
but also offers states paths toward greater flexibility.
There is a set of documents that can be
helpful in finding the details of a state’s Medicaid program, because they
describe how a state takes advantage of options for flexibility. This
blog post briefly describes these documents and where to find them.
Medicaid State Plans
A Medicaid State Plan sets forth how a
state Medicaid agency will operate its Medicaid program in accordance with
federal law. Typically about a thousand pages long, the Medicaid state plan
includes information about who is eligible for Medicaid, what services are
available, and how Medicaid providers get paid. Within federal Medicaid law,
there are various “state plan options,” for example, the option to provide
dental services or the option to offer care through Health Homes. Medicaid
state plans contain information about whether a state has selected a state plan
option or not.
Medicaid state plans are available
online for the following states and territories: Alabama,
Alaska,
Arizona,
Arkansas,
California,
Colorado,
Delaware,
Florida,
Georgia, Guam,
Hawaii,
Idaho,
Indiana,
Iowa,
Kansas,
Kentucky,
Louisiana, Michigan,
Mississippi, Nebraska,
Nevada,
New Jersey,
New Mexico,
New York,
North Carolina,
Ohio,
Oklahoma, Puerto Rico,
South Carolina,
South Dakota,
Tennessee,
Texas,
Vermont,
Washington State,
West Virginia,
Wisconsin,
and Wyoming.
State plans posted online are not always up to date; make sure to check the
effective date and look for state plan amendments posted after that date (see
the next section).
Medicaid State Plan Amendments
When a state wants to change its
Medicaid state plan, it submits a state plan amendment to the federal
government. These state plan amendments can be used to update Medicaid
state plans, described above. The Secretary of the United States Department of
Health and Human Services, or HHS, must approve the amendment before it can
take effect. Recently approved state plan amendments are available here.
Waiver documents
Sometimes, a state wants to make
changes to its Medicaid program that are not available through a state plan
option. In those cases, a state may submit a waiver application to be
approved at the discretion of the HHS Secretary and in accordance with specific
programmatic and financial requirements.
·
Section 1115 waivers offer broad waiver and expenditure
authorities to states. Changes approved under Section 1115 waivers can
affect eligibility, services, and service delivery. For example, one of Oregon’s
1115 waivers moves care delivery to Coordinated Care Organizations (CCOs).
Pending and approved 1115 Demonstration documents are available here.
·
Section 1915(c) waivers offer states an opportunity to provide
long-term services and supports in the community, rather than in an institution
like a nursing home. Approved 1915(c) applications set out the parameters
of the 1915(c) program, and are available here.
·
Section 1915(b) waivers offer states an opportunity to waive
various parts of federal Medicaid law related to delivery systems. Approved
1915(b) applications set forth parameters associated with 1915(b) waivers, and
are available here.
Flexibility available through the
Center for Medicare and Medicaid Innovation
The Center for Medicare and Medicaid
Innovation (CMMI) has the authority to grant state Medicaid agencies additional
flexibility (technically available through Section 1115A of the Social Security
Act).
·
Duals Demonstration projects are projects that offer states an
opportunity to align member experiences for individuals who receive both
Medicaid and Medicare. Duals Demonstration materials are available here.
·
Other CMMI projects offer states additional ways to modify
their Medicaid programs. Information is available here.
Conclusion
State Medicaid programs vary from state
to state. These documents and links can help interested parties navigate
these variations. This blog post focused solely on the documents that
memorialize agreements between a state and the federal government regarding
areas of state flexibility and variation. For a broad understanding of
how Medicaid functions and the requirements a state must follow, these
documents should be read within the context of federal and state statutes,
regulations, guidance materials, administrative decisions, court cases, and
procurement materials.
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