Montana Medicaid History and Facts

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Initial Medicaid Implementation: Prior to the implementation of the Medicaid program, Montana had a program that helped low-income seniors under the Kerr-Mills legislation. The plan was not generous and paid approximately 19 cents for medical care for every beneficiary on the program. Montana began their Medicaid program in July of 1967. When the program began, the state decided not to cover the “medically indigent” or the medically necessary population.

Key Medicaid Political Issues: The state has had several expansions of coverage outside of the ACA’s Medicaid expansion. The state enhanced provider payments and extended long-term care coverage while making the application process easier for beneficiaries in 2011-2012. Montana’s other main Medicaid issues have focused on issues related to the rural nature of the state.

Medicaid Expansion Implementation: Montana had rejected several attempts to expand Medicaid in 2013 ad 2014. The Democratic governor, Steve Bullock had long supported Medicaid expansion and proposed several policies that would have expanded either through a waiver or through the traditional expansion. A 2013 plan had bipartisan support in the legislature but failed to pass. In 2014 there was a campaign to get Medicaid expansion on the ballot through referendum but failed to collect enough signatures. Montana expanded Medicaid effective January 1, 2016. The state included a waiver that was approved by CMS in November of 2015. The waiver requires beneficiaries to pay a premium that is 2% of their income and enrollees that fail to pay their premium are barred from reenrolling for three months. The state included a sunset date in the original legislation of 2019 and whether the sunsetting of the legislation should continue is under debate in the 2018 elections. In November 2018, Montana will vote on continuing the Medicaid expansion with a change to the proposed revenue source. The state will vote whether to fund Medicaid expansion through an increase to the state’s cigarette tax.

General facts about Montana Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Healthy Montana Kids (HMK) Plus

Separate or combined CHIP: Combination

Medicaid Enrollment: 279,000 (2018 estimate)

Total Medicaid Spending: $1.8 billion (FY 2017 estimates)

Share of total population covered by Medicaid: 22%

Share of Children covered by Medicaid: 44% (estimate)

Share of Medicaid that is Children and Adults: 71%

Share of Spending on Elderly and people with disabilities: 59%

Share of Nursing Facility Residents covered by Medicaid: 60% (estimate)

FMAP: 65.54%

Expansion state: Yes

Number of people in expansion: 58,000 (2018 estimate)

Work Requirement: No

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Missouri Medicaid History and Facts

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Initial Medicaid Implementation: Prior to the implementation of the Medicaid program, Missouri ran a medical assistance program through the Kerr-Mills legislation. This program provided hospital and limited prescription drug and dental benefits. Medicaid was signed into law in Independence Missouri, home place of President Truman. Missouri began their Medicaid program in through the legislature’s adoption of Medicaid in October of 1967. When the program began, Missouri had no program for the medically indigent. The state did extend benefits to child welfare beneficiaries and blind people using state dollars prior to these categories of eligibility receiving federal Medicaid reimbursement.

Key Medicaid Political Issues: Although the Welfare reforms of 1996 ended the link between Medicaid and TANF, the state maintained many of the eligibility criteria for low-income residents through 2005. In 2005 the state eliminated the benefits for adults unless they met the minimum categories of pregnant of blind as defined by federal law. In 2007 the state passed a law requiring the program to be known as MO HealthNet in addition to Medicaid. The state in recent years has implemented several more regressive policies designed to make Medicaid coverage more difficult to obtain and maintain for beneficiaries. In 2016 the state enacted a law that would penalize Medicaid patients for missed appointments. The state has been at the center of the debate surrounding the defunding of Planned Parenthood.

Medicaid Expansion Implementation: Missouri has not expanded Medicaid. The state had a Democratic governor (Jay Nixon) and a Republican legislature for a large portion of the period that Medicaid expansion was being discussed. In 2014 the legislature debated a measure to expand Medicaid coverage. The Chamber of Commerce and local groups including a coalition of faith leaders have been active in supporting expansion and have supported plans to expand via referendum.

General facts about Missouri Medicaid:

Medicaid program name: Medicaid/MO HealthNet

CHIP Program name: MO HealthNet for Kids

Separate or combined CHIP: Combination

Medicaid Enrollment: 933,000 (2018 estimate)

Total Medicaid Spending: $10.2 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 15%

Share of Children covered by Medicaid: 33% (estimate)

Share of Medicaid that is Children and Adults: 73%

Share of Spending on Elderly and people with disabilities: 70%

Share of Nursing Facility Residents covered by Medicaid: 66%

FMAP: 65.4%

Expansion state: No

Number of people in expansion: N/A

Work Requirement: No

Mississippi Medicaid History and Facts

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Initial Medicaid Implementation: Before Medicaid was passed, the state began a program for elderly low-income individuals through the Kerr-Mills program. The state started the program in 1964 only one year before the passage of Medicaid. Mississippi initially began their Medicaid program on January 1, 1970, the “deadline” to begin their Medicaid program, or the day the Kerr-Mills funding ended. The initial plan had modest benefits as Mississippi historically has had lower state funding and government oversight.

Key Medicaid Political Issues: Mississippi has a largely poor and rural population with a proportion of adults with high chronic diseases. The state receives the largest proportions of federal dollars (an FMAP of 74.17%) for the Medicaid program with the state only contributing 16 cents for every Medicaid dollar spent in the state. In 2011 the legislature authorized a program called MississippiCAN or the Coordinated Access Network which is the state’s managed care program. Approximately 65% of Medicaid beneficiaries participate in a MississippiCAN plan, lower than the national average. The program includes behavioral health services and covers individuals on Medicaid outside of the elderly and disabled populations. Prior to the establishment of the MississippiCAN program, managed care only covered 8% of beneficiaries.

Medicaid Expansion Implementation: Mississippi hasn’t expanded their Medicaid program. Following the coverage expansions of 2014 the state saw an enrollment growth of approximately 10% due to the welcome mat effect. In 2017 the state proposed a Medicaid work requirement to CMS for their parent and certain medically necessity adult populations. In 2017 Mississippi became the first state to receive a 10-year 1115 waiver that provides family planning services at higher income levels. The courts have prevented the state from barring Planned Parenthood from receiving these funds but challenges are ongoing.

General facts about Mississippi Medicaid:

Medicaid program name: Medicaid

CHIP Program name: CHIP

Separate or combined CHIP: Separate CHIP

Medicaid Enrollment: 640,000 (2018 estimate)

Total Medicaid Spending: $5.5 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 24%

Share of Children covered by Medicaid: 50% (estimate)

Share of Medicaid that is Children and Adults: 65%

Share of Spending on Elderly and people with disabilities: 68%

Share of Nursing Facility Residents covered by Medicaid: 75%

FMAP: 76.39%

Expansion state: No

Number of people in expansion: N/A

Work Requirement: No* under review by CMS

Minnesota Medicaid History and Facts

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Initial Medicaid Implementation: Prior to the implementation of the Medicaid program, Minnesota ran a Kerr-Mills program that together with 4 other states took nearly 2/3rds of the funds for the nationwide program. The program unlike many other states provided comprehensive medical benefits. Minnesota initially began its Medicaid program in January of 1966, the first opportunity that the state had to implement Medicaid. When the program began it was estimated that 5% of the population was eligible for Medicaid. Again, the benefits offered were comprehensive with Minnesota being one of five states to offer all services to which the federal government would reimburse.

Key Medicaid Political Issues: Minnesota has made several efforts to integrate delivery system reforms and efforts to integrate social determinants of health into their Medicaid program. In 1983 the state began a program named PMAP that provided payments to HMOs particularly for rural areas. These nonprofit HMOs provided health care services to low-income residents at higher eligibility rates than the national average under the Medicaid program prior to the expansion of coverage. Today, approximately 750,000 Minnesota residents receive services through the PMAP program. Minnesota has generous optional benefits available to all residents including coverage of doula services and vision and dental benefits that are more generously available.

Medicaid Expansion Implementation: Minnesota expanded Medicaid with coverage beginning on January 1st, 2014 and enrollment beginning in October of 2013. Minnesota ran their own exchange which made integration with their Medicaid program more seamless than states that used the federal infrastructure. The state runs a Basic Health Program which provides an insurance option to people making under 200% FPL. The Governor proposed a plan that would add a Medicaid Buy In program to the state’s Medicaid expansion and basic health programs. The program did not gain traction in the legislature. In 2018 members of the Minnesota legislature proposed adding work requirements for the expansion population, however that proposal did not gain traction in the legislature.

General facts about Minnesota Medicaid:

Medicaid program name: Medical Assistance (Medicaid)

CHIP Program name: MinnesotaCare

Separate or combined CHIP: Combination

Medicaid Enrollment: 1.07 million

Total Medicaid Spending: $11.5 billion (FY2017 estimate)

Share of total population covered by Medicaid: 14%

Share of Children covered by Medicaid: 25% (estimate)

Share of Medicaid that is Children and Adults: 80%

Share of Spending on Elderly and people with disabilities: 58%

Share of Nursing Facility Residents covered by Medicaid: 50%

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 223,000 (2018)

Work Requirement: No

Michigan Medicaid History and Facts

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Initial Medicaid Implementation: Michigan was crucial to the initial passage of the Medicaid and Medicare law. It was at University of Michigan where President Johnson gave his Great Society speech in 1964 and Michigan Senator McNamara was in opposition of early Medicare and Medicaid legislation because he opposed to cost sharing or any income test in Medicare. Michigan began their Medicaid program in October of 1966. When the program began it was estimated that 4 percent of the states residents enrolled in Medicaid coverage. By 1967 Michigan’s Medicaid program was already running fiscal deficits and substantial payments were being made to non-welfare cases because the eligibility levels were well above welfare eligibility levels. Michigan began to be concerned with fraud and high payment rates of physicians finding that one physician was paid as much as $169,000 from the Medicaid program.

Key Medicaid Political Issues: Michigan has delivered services through HMOs since the early 1970’s. In 1997 the state fully privatized the system, including the disabled population. The state was an early adopter in providing services through a HMO to disabled individuals. Through the late 2000’s and early 2010’s the state continued to make MCO enrollment mandatory for special eligibility groups including dual eligible through the CMMI demonstrations.

Medicaid Expansion Implementation: Michigan expanded their Medicaid program in 2013 with benefits beginning on April 1, 2014. The Centers for Medicare and Medicaid Services (CMS) approved a waiver for Michigan’s Medicaid expansion alternative plan on December 30, 2013. This plan, known as the Healthy Michigan plan used the premium assistance program similar to Arkansas and Iowa’s waiver applications, premiums and additional cost sharing, and certain wellness program benefits that can reduce medical expenditures for the beneficiary if the person participates in a wellness program. In 2017 the state legislature voted to approve a plan that would add work requirements to the Medicaid expansion program. The plan was widely critiqued for exempting certain predominately white counties while subjecting urban predominately African American counties to the requirement. The legislature decided not to include this policy in the final bill that was approved by the legislature. The work requirement waiver is currently under review with CMS. Aside from the addition of work requirements, the state’s 1115 waiver ends the premium assistance program

General facts about Michigan Medicaid:

Medicaid program name: Medicaid

CHIP Program name: MICHIP

Separate or combined CHIP: Combination

Medicaid Enrollment: 2.3 million (2018 estimate)

Total Medicaid Spending: $16.8 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 22%

Share of Children covered by Medicaid: 40% (estimate)

Share of Medicaid that is Children and Adults: 78%

Share of Spending on Elderly and people with disabilities: 62%

Share of Nursing Facility Residents covered by Medicaid: 60% (estimate)

FMAP: 64.45%

Expansion state: Yes

Number of people in expansion: 637,000 (2017 estimate)

Work Requirement: No* under consideration by CMS

Massachusetts Medicaid History and Facts

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Initial Medicaid Implementation: Prior to the implementation of the Medicaid program, Massachusetts operated a comprehensive benefit program that covered low-income seniors under the Kerr-Mills legislation. Massachusetts initially began the state’s Medicaid program in September of 1966 becoming the 23rd state to implement the program. When the program began, it was estimated that approximately 7% of Massachusetts residents would be eligible for Medicaid in the first few years that the program was implemented. In 1968 the federal government proposed reducing the matching rate for wealthier states which would have led to $40 million less in federal dollars for Massachusetts. In response to fiscal pressures in 1969 the governor reduced eligibility levels through executive order. One of the main issues in the early years of Medicaid implementation in the state was how providers would be paid. The Massachusetts Medical Association objected to the new payment paperwork designed to work with the new computing system. Physicians also argued for Blue Shield to be the fiscal agent for the program.

Key Medicaid Political Issues: The state has had a history of adopting broad health care reforms. In 1988, then governor Michael Dukakis signed the Health Security Act into law which would have provided health insurance to all residents by 1992. It had an employer mandate and provided Medicaid coverage to former welfare recipients. In 1995 through 1997 the state implemented its first 1115 waiver that extended health care and created additional cost efficiencies. At the same time the state renamed their Medicaid program MassHealth. The state also took major early efforts to provide personal care attendant services and home care options to seniors and people with disabilities through a variety of programs. In 2006 then governor Mitt Romney signed the Masssachusetts Healthcare Reform Bill which included an individual mandate, a state health insurance program, employer fair share contributions and an expansion of the Medicaid program. The latest focus of the MassHealth program has been on cost containment after the state after the passage of the cost containment strategy bill through delivery system reforms.

Medicaid Expansion Implementation: Massachusetts’s 2006 reforms were used as the blueprint for the national 2014 health coverage reforms. However, there were significant changes that required the state to make changes to their eligibility and enrollment systems. The state was not prepared for these changes at the time of the open enrollment period starting in October 2013 and requested a waiver to provide applicants with Medicaid fee-for-service coverage while their eligibility was being determined by the state.

General facts about Massachusetts Medicaid:

Medicaid program name: MassHealth

CHIP Program name: MassHealth

Separate or combined CHIP: Combination

Medicaid Enrollment: 1.6 million (2018 estimate)

Total Medicaid Spending: $17.3 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 23% (estimate)

Share of Children covered by Medicaid: 33%

Share of Medicaid that is Children and Adults: 70% (estimate)

Share of Spending on Elderly and people with disabilities: 58% (estimate)

Share of Nursing Facility Residents covered by Medicaid: 66% (estimate)

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 398,300

Work Requirement: No

Maryland Medicaid History and Facts

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Initial Medicaid Implementation: Maryland initially began their Medicaid program on July 1, 1966. In the first year the state enrolled 113,000 people. When Medicaid began, it was estimated that 9.7% of the state’s population would be eligible. In the end by 1969 7.2% of the population or approximately 260,000 people signed up for Medicaid in the first years of the program. In 1967 when federal legislation created a cutoff of 150% AFDC for eligibility for federal funding, Maryland decided to reduce their eligibility levels. In 1968 the program was facing budgetary pressures and substantial portions of the payments were being made to non-welfare patients and there were costs attributed to high costs of hospitals that led the governor to reduce eligibility levels from $3,120 to $3,000 for a family of four. This cut approximately 22,000 people from the program or approximately 10% of the beneficiaries. These beneficiaries were restored eligibility within 6 months of being cut off of coverage. The hospitals continued to be paid at usual and customary levels which meant that the Medicaid program depleted their funds early in the year and hospitals experienced many unpaid bills. The state began taking additional action against finding overpayments and fraudulent charges by physicians, pharmacists, and dentists and 10 physicians were found to have made fraudulent charges and were prosecuted for the crime. It was later found that 28 physicians received a combined $800,0000 and through the convictions $68,000 were returned to the state.

Key Medicaid Political Issues: For the first nine years of the Medicaid program the state operated exclusively through a fee for service model. Then in 1975 six HMOs in the state began offering coverage for preventive services to Medicaid beneficiaries. In 1997 the state implemented the HealthChoice program, a mandatory managed care program that covered 80% of the state’s Medicaid beneficiaries. In 2006 the state began offering pharmacy and primary care services to adults earning 116 percent of the federal poverty level or below, paving the way for more enhanced benefits to the same population through Medicaid expansion. Maryland’s unique payment model for hospitals means that Medicare and private payers pay the same rate as Medicaid.

Medicaid Expansion Implementation: Maryland expanded Medicaid in January 2014 with enrollment beginning in October of 2013. Despite the fact that Maryland was one of several states that switched gubernatorial party control in 2015, no significant changes have been made to the state’s Medicaid expansion program, in part due to the Democratic control of the legislature. In 2012 the state wrote that the potential for increased economic activity resulting from the infusion of federal dollars was a main reason that they decided to expand coverage. Additionally, the state made the argument that many existing programs could be ended because they would be duplicative, therefore there was the potential of saving the state money in the short term even if the program would require the state to pay 10% of the medical costs in the long run. The state also argued that reduced uncompensated care would reduce costs for private market consumers and that expanding Medicaid would ensure that there are no gaps in coverage.

General facts about Maryland Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Maryland Children’s Health Program (MCHP)

Separate or combined CHIP: Medicaid Expansion

Medicaid Enrollment: 1.3 million (2018 estimate)

Total Medicaid Spending: $11.2 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 16% (estimate)

Share of Children covered by Medicaid: 30% (estimate)

Share of Medicaid that is Children and Adults: 83% (estimate)

Share of Spending on Elderly and people with disabilities: 58% (estimate)

Share of Nursing Facility Residents covered by Medicaid: 60% (estimate)

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 277,000

Work Requirement: No