This amendment adds language to provide authority for the Department of Medical Assistance Services to seek approval from the Centers for Medicare and Medicaid (CMS) to enhance Medicaid coverage to certain low income individuals pursuant to the federal Patient Protection and Affordable Care Act (ACA) within 45 days of the effectiveness of this act. Language requires DMAS to seek federal approval for a State Plan amendment, while simultaneously seeking approval for a Medicaid demonstration waiver to promote efficiency, accountability, personal responsibility, and competitive, value-based purchasing of health care to provide a model of health coverage for participants that is fiscally sustainable and cost effective. Language requires the Department of Medical Assistance Services to transform the Medicaid program for newly eligible individuals pursuant to the federal Patient Protection and Affordability Act (ACA) and the existing Medicaid program.

Language requires that DMAS submit the § 1115 demonstration application to CMS for approval no later than 150 days from the passage of this act. If the State Plan amendments are affirmatively approved by CMS prior to the submission of the waiver, Medicaid coverage for newly eligible individuals may be implemented; however, if the State Plan amendment becomes effective without affirmative action by CMS, coverage may begin upon submission of the completed § 1115 demonstration application, but no later than January 1, 2019. If the demonstration waiver cannot be completed by 150 days, despite a good faith effort to complete the application, the department may request an extension from the Chairmen of the House Appropriations and Senate Finance Committees. Language requires DMAS to provide updates on the progress of the State Plan amendments and waiver applications to the Chairmen of the House Appropriations and Senate Finance Committees upon request and provide for participation in discussions with CMS staff. The department is required to respond to questions from the federal Centers for Medicare and Medicaid on the proposed state plan amendments and demonstration waiver application in a timely manner. Further, the agency is required to notify and submit a copy of the demonstration waiver application at least 10 days prior to federal submission to the Chairmen of the House Appropriations and Senate Finance Committees. If an objection to the demonstration waiver application is made by either Chairman, the department shall make all reasonable attempts to address the objection(s) and modify the waiver. Language requires DMAS to include several provisions through the State Plan amendments, contracts or policy changes such as, referrals to job training, education and job placement assistance for all unemployed, able-bodied adult enrollees. In addition, DMAS is required to include provisions to foster personal responsibility and prepare enrollees for participation in health insurance plans to include use of Medicaid private managed care health plans, premium support for employer-sponsored insurance, health and wellness accounts, appropriate utilization of hospital emergency room services, healthy behavior incentives, and enhanced fraud prevention efforts.

The demonstration waiver requires the development of a premium assistance program for individuals between 100% and 138% of the federal poverty level. It provides for a robust benefit package which includes mental health services and addiction recovery and treatment services. The premium assistance program would include the development of a health and wellness account for eligible individuals comprised of individual contributions and state funding, monthly individual contributions based on a sliding scale not to exceed two percent of monthly income, provisions for the date coverage begins, provisions for a grace period followed by a waiting period prior to re-enrollment if the premium is not paid, and provisions to recover premium payments owed through debt set-off collections. The waiver also requires cost sharing to encourage personal responsibility for individuals with incomes between 100% and 138% of the federal poverty level. However, individuals meeting one of ten exemptions to the Medicaid Training, Education, Employment, and Opportunity Program (TEEOP) would not be subject to cost sharing requirements more stringent than existing Medicaid law or regulations. Enrollees who comply with provisions of the demonstration program, including engaging in healthy behaviors, may receive a decrease in their monthly premiums and copayments, not to exceed 50 percent.
Individuals with incomes between 0 and 100% of the federal poverty level would be enrolled in existing Medicaid private managed care plans with existing Medicaid benefits, subject to existing Medicaid cost sharing requirements.
The language includes requirements that the demonstration waiver engage individuals enrolled in Medicaid in the TEEOP to enable them to increase their health and well-being through community engagement leading to self-sufficiency. Individuals meeting certain exemptions would not be subject to the TEEOP requirements, however, individuals who do not meet the TEEOP requirements three months out of a 12-month period beginning with the first day of enrollment would be disenrolled from the program and will not be permitted to re-enroll until the end of such 12-month period, unless the failure to comply or report compliance was the result of a catastrophic event or circumstances beyond the beneficiary's control. However, the individual may re-enroll in the program upon demonstration of compliance with TEEOP requirements. Language also directs the agency to develop a supportive employment and housing benefit for certain high risk Medicaid beneficiaries who need intensive, ongoing support to obtain and maintain employment and stable housing.

Language is also added to require both the State Plan amendments and demonstration waiver application to include systems for determining eligibility for participation in the program, provisions for disenrollment if federal funding is reduced or terminated and an evaluation component for the project. Finally, language is added to authorize the agency to implement the provisions of the language prior to the completion of the regulatory process.