Total Number of Enrollees
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The 2017 OPEN MINDS Medicaid Managed Care Update: A State-By-State Analysis, August 2017
- Expands Medicaid coverage to newly eligible adults ages 19-64 through a managed FFS TPA. In order to implement the TPA, the state has approval to waive freedom of choice requirements (except for family planning providers) so that newly eligible adults will receive services from the TPA’s provider network.
- Exempts certain groups of people from enrolling in the TPA and all of the Section 1115 waiver provisions except 12-month continuous eligibility including those with incomes at or below 50% FPL, American Indian/Alaskan Natives, individuals who are medially frail, those with exceptional health care needs as determined by the state, people who live in regions where there are an insufficient number of providers contracted with the TPA, and people who require continuity of coverage not available or effectively delivered through the TPA.
- Requires monthly premiums up to 2% of household income for newly eligible adults from 51-138% FPL receiving services through the TPA. Beneficiaries from 101-138% FPL may be dis-enrolled for failing to pay premiums after notice and a 90 day grace period. These beneficiaries may re-enroll upon payment of arrears or when the state Department of Revenue assesses the debt against income taxes, no later than the end of the quarter; re-enrollment shall not require a new application. The state shall establish a process to exempt beneficiaries from dis-enrollment for good cause.
- Subjects enrollees to premiums and copayments up to 5% of income, consistent with federal limits. Beneficiaries subject to premiums will receive a credit toward co-payments accrued up to 2% of income. Certain service categories are exempt from co-payments (including preventive health care, immunizations and medically necessary health screenings), and providers may not deny services for failure to pay copayments for individuals with incomes below poverty.
- Implements twelve month continuous eligibility for all newly eligible adults to reduce the effects of churning between Medicaid and Marketplace coverage as income fluctuates.