On Tuesday, the Centers for Medicare and Medicaid Services (CMS) approved Nebraska’s Section 1115 demonstration waiver request to provide “prime” benefits to Medicaid expansion enrollees who agree to complete community engagement and wellness requirements. Prime benefits include dental, vision, and over-the-counter drug coverage.
In order to comply with the wellness component, enrollees must choose a primary care provider, have an annual clinic visit, and participate in active care and case management. Working, volunteering, or attending post-secondary classes for a combined total of at least 80 hours per month is required for the community engagement component. Enrollees must satisfy both components to access prime benefits. Enrollees who fail to comply will not lose all Medicaid coverage, but will revert to the basic benefit package required by law.
Just last week, CMS approved Georgia’s request for a partial Medicaid expansion for individuals up to 100% of the federal poverty level (roughly $13,000 annually). To become eligible and maintain coverage, individuals must meet premium and community engagement requirements, which may include work, education, or other qualifying activities.
As has been the case with other states that previously requested partial Medicaid expansions, including Arkansas, CMS refused to authorize enhanced federal funds to pay for the waiver program. CMS has consistently held that the Affordable Care Act (ACA) authorizes enhanced federal funding only to states that offer full Medicaid expansion to individuals with incomes up to 138% of the FPL (roughly $18,000 annually).
CMS also approved Georgia’s Section 1332 waiver request to implement a reinsurance program with the goal to reduce premiums in the state’s individual insurance market and a plan to eliminate Georgians’ access to the federal health insurance enrollment platform, www.healthcare.gov. Instead, Georgians will shop for and enroll in plans directly through insurance agents and brokers and health insurance companies, a pathway already available to them today.
Section 1332 waivers allow states to waive ACA requirements such as essential health benefit requirements, cost sharing limits, and premium tax credits for coverage. However, there are guardrails that limit Section 1332 flexibility, requiring states to demonstrate that they will provide coverage that is at least as comprehensive and affordable, cover at least a comparable number of residents, and not increase the federal deficit. CMS has approved Section 1332 for 16 states, with most of the requests seeking waivers to implement reinsurance programs.
CMS has approved 11 Section 1115 waiver requests including work and community engagement requirements, and four of them — including Arkansas’s — have been halted by the courts. In July, Arkansas appealed a federal court of appeals ruling to the U.S. Supreme Court, a petition that remains under consideration by the high court.
