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tenia' 




INTERGOVERNMENTAL HEALTH POLICY PROJECT 
' George Washington University 



REPORTS 
RA 
412 
4 

R38 
1984 
July 



eorge i 



ith the assistance ol the 



STATE MEDICAID INFORMATION CENTER 
National Governors' Association 
Center For Policy Research 



H\i.<i 

RECENT AND PROPOSED CHANGES IN STATE MEDICAID PROGRAMS 

T "' y A Fifty State Survey 

July 1984 




Compiled by 

INTERGOVERNMENTAL HEALTH POLICY PROJECT 
George Washington University 

with the assistance ot the 

STATE MEDICAID INFORMATION CENTER 
National Governors' Association 
Cenler For Policy Research 



Available from: 



Intergovernmental Health Policy Project 
2100 Pennsylvania Ave., N.W. 
Suite 616 

Washington, DC 20037 

List price: $7.00 (Add $2.00 shipping 
and handling) 

Copyright © 1984, Intergovernmental Health 
Policy Project, George Washington University 



INTRODUCTION 



Efforts to control the rate of growth in Medicaid expen- 
ditures have dominated the health policy agendas of most 
states during the early 1980s. Medicaid outlays for FY 84 are 
expected to approach $38.3 billion— almost 25 times the $1.5 
billion spent during 1966, the program's first full year of 
operation. Between the fiscal years 1975 and 1981, the 
average annual rate of increase in Medicaid expenditures 
was slightly more than 15 percent. However, fiscal years FY 
82 and 38 experienced sharp reductions in the rates of in- 
crease in Medicaid expenditures, with each of the two years 
growing at less than double digit rates. Compared to a 1 7 per- 
cent increase in FY 81, federal-state payments for Medicaid 
increased only 6.7 percent in FY 82 over FY 81 , and only 9.6 
percent in FY 83 over FY 82. 

How much of the recent slowdown in the growth of 
Medicaid expenditures can be attributed to new state in- 
itiatives and experimentation in the organization, financing 
and reimbursement of services, as opposed to reduced 
federal financial participation, or federal and state policies 
constricting eligibility and benefits, cannot easily be determin- 
ed. Nevertheless, several state officials have singled out in- 
creased program flexibility, especially with respect to institu- 
tional reimbursement and new waiver opportunities, as con- 
tributing significantly to their ability to constrain the growth in 
their programs. 

The July, 1984 survey is the eighth in a series on state 
Medicaid changes issued by IHPP since January 1981. This 
survey, like the preceding ones, attempts to provide as com- 
prehensive a list of Medicaid policy changes — both legislative 
and executive— as possible. Information included in this 
report was obtained from three principal sources: 1) a review 
of all state legislative proposals and laws affecting Medicaid 
policy; 2) the State Medicaid Information Center at the Na- 
tional Governors' Association; and 3) telephone conversa- 
tions with key state health policymakers and staff. 



Although every effort has been made to chronicle all the 
proposed and adopted changes In the Medicaid programs 
through the end of July, 1 984, undoubtedly a few changes will 
be missed. Readers are encouraged to forward any omissions 
or corrections to IHPP to be incorporated In the end of the 
year survey (December, 1984). 

A review of the data in the July, 1984 survey reveals that no 
state adopted the sweeping kinds of cuts and restrictions In 
program eligibility and services which so characterized state 
programs in 1981 and to a lesser extent In 1982. In fact, a 
reversal of those earlier trends seems to be developing. In 
1983, for example, 15 states adopted policies leading to an 
expansion in program eligibility and so far in 1984, nine states 
have expanded eligibility. Most of the recent increases have 
been through the introduction of limited medically needy pro- 
grams which focus on services for pregnant women and 
children. Also, in 1984, 14 states either added a new service 
or reinstated a previous service which had been cut, while on- 
ly one state acted to eliminate a service. 

The recently adopted Deficit Reduction Act of 1984 made 
some important changes in Medicaid eligibility requirements. 
States will be required to cover the following groups meeting 
the AFDC income and resource criteria; first-time pregnant 
women from the point where the pregnancy is medically 
verified; pregnant women (again from the point where the 
pregnancy is medically verified) in intact families where the 
principal wage-earner is unemployed (AFDC-U Program); and 
children born on or after October 1, 1983, up to age 5, in in- 
tact families. The new law also permits the Department of 
Health and Human Services to modify, under certain cir- 
cumstances, the requirement that the total number of 
Medicaid and Medicare recipients enrolled in a particular 
HMO cannot exceed 75%. The Senate provision that would 
have reduced the federal match by 3% for the next 3 fiscal 
years, was not adopted. 



The compilation and analysis of Iho legislative data In this 
survey was dono by Randy Dosonla, Research Associate with 
IHPP. Data related lo executive changes were provided 
primarily by the Stato Medicaid Information Center at the Na- 
tional Governor's Assoclallon. We are grateful to Mssrs. Larry 
Barflott and John Luohrs al the Center, and Mr. Rick Curtis, 
Director of Health Policy Projects al NGA, for their contribu- 
tions and assistance. Wo also express our appreciation to the 
state Medicaid directors and their staffs for their continued 
cooperation and assistance In sharing informafion with our 
project about new initiatives affecting their states' programs. 

This series of surveys of changes In state Medicaid pro- 
grams is an outgrowth of the mission of the Intergovernmental 
Health Policy Project to monitor and report on important state 
practices and Innovations as a focus for future discussion, 



analysis and problem solving. It is our hope that this survey 
will be a useful resource to state and federal health 
policymakers and analysts and will contribute to the overall 
improvement of state Medicaid management and program 
performance. 



Richard E. Merritt 
Director 

Intergovernmental Health 
Policy Project 



SERVICES 

• Fourteen slates either added at least one new service or 
reinstated a service which had previously been eliminated. 
For example: South Dakota expanded coverage of dental ser- 
vices for recipients over age 21; South Carolina added per- 
sonal care, respite, and medical day care services; and 
Oregon now purchases Medicare Part B coverage tor mental 
health clients. 

• So far, in 1984 only Mississippi has eliminated any services 
(coverage of Part A of Medicare). 

• Three states relaxed their limits on certain services. South 
Carolina extended their inpatient hospital limit tor EPSDT 
recipients from 12 days to 28 days per year. 

• Three states imposed more restrictive limits on the 
coverage of certain services. For example, Mississippi reduc- 
ed coverage of inpatient hospital days from 20 to 15 days per 
year. 

• Three states— Colorado, Mississippi, and Penn- 
sylvania — adopted copaymenj reguirements for the first time, 
while three other states expanded their copay policies. Kan- 
sas increased the copay amount for an outpatient hospital 
visit, and North Carolina extended its outpatient hospital 
copay to the categorically needy. 

• Three states eliminated or relaxed their copay policies, 
Michigan eliminated its copay under the Wayne County 
Primary Care Sponsorship Program, and New Jersey 
adopted legislation which prohibits copays unless mandated 
by federal law. 

• Maryland and Missouri added coverage of liver transplants, 
while Idaho eliminated coverage of solid organ transplants ex- 
cept kidney and liver. California is considering creating a 
Medical-Surgical Therapeutic Advisory Committee to review 
experimental procedures for possible coverage. 

ELIGIBILITY 

• Nine states adopted policies resulting in an expansion of 
program eligibility. Florida adopted a medically needy pro- 
gram (effective mid-1986) and expanded eligibility for 



HIGHLIGHTS 



children in intact families, married pregnant women and 
families with an unemployed parent and their children under 
18 (effective mid- 1985). South Carolina and Iowa created 
limited medically needy programs. 

• Of these nine states, eight added prenatal or delivery ser- 
vices to pregnant women, and five added some type of 
coverage for certain children. 

• One state, Mississippi, delayed funding of Its recently 
established limited Medically Needy program for pregnant 
women and for children under 18. 

• Three states increased their Income eligibility standards 
making it easier for more individuals to qualify lor assistance. 

REIMBURSEMENT 

• In 1984, eight states authorized significant changes in their 
hospital reimbursement methodologies. 

• Five states— Pennsylvania, Ohio, Michigan, Minnesota, and 
Washington— set in motion plans to implement new prospec- 
tive reimbursement systems for hospital inpatient services 
based on diagnostic related groups (DRGs). Two other 
stales— Indiana and North Carolina— are giving serious con- 
sideration to implementing a DRG based system for 
Medicaid. 

• Arkansas adopted an alternative inpatient hospital reim- 
bursement system. Illinois and Nebraska authorized contrac- 
ting for hospital services on a bid or negotiated basis. 

• Minnesota legislation directs the state agency to develop a 
nursing home payment system that accounts for the case 
mix. Connecticut is studying the feasibility of implementing a 
case mix reimbursement methodology for nursing homes. 

• Five stales increased their drug dispensing fees, although 
Connecticut's increase was limited to the bonus pharmacists 
receive for substitution a generically equivalent drug. 

ADMINISTRATION & MANAGEMENT 

• Georgia and Connecticut adopted, Utah expanded, and 
Kansas automated a recipient lock-in program for high 
utilizers. 



SURVEY HIGHLIGHTS 



SERVICES 

• Fourteen states either added at least one new service or 
reinstated a service which had previously been eliminated. 
For example: South Dakota expanded coverage of dental ser- 
vices for recipients over age 21; South Carolina added per- 
sonal care, respite, and medical day care services; and 
Oregon now purchases Medicare Part B coverage for mental 
health clients. 

• So far, in 1984 only Mississippi has eliminated any services 
(coverage of Part A of Medicare). 

• Three states relaxed their limits on certain services. South 
Carolina extended their inpatient hospital limit for EPSDT 
recipients from 12 days to 28 days per year. 

• Three states imposed more restrictive limits on the 
coverage of certain services. For example, Mississippi reduc- 
ed coverage of inpatient hospital days from 20 to 15 days per 
year. 

• Three states— Colorado. Mississippi, and Penn- 
sylvania — adopted copayment requirements for the first time, 
while three other states expanded their copay policies. Kan- 
sas increased the copay amount for an outpatient hospital 
visit, and North Carolina extended its outpatient hospital 
copay to the categorically needy. 

• Three states eliminated or relaxed their copay policies. 
Michigan eliminated its copay under the Wayne County 
Primary Care Sponsorship Program, and New Jersey 
adopted legislation which prohibits copays unless mandated 
by federal law. 

• Maryland and Missouri added coverage of liver transplants, 
while Idaho eliminated coverage of solid organ transplants ex- 
cept kidney and liver. California is considering creating a 
Medical-Surgical Therapeutic Advisory Committee to review 
experimental procedures for possible coverage. 

ELIGIBILITY 

• Nine states adopted policies resulting in an expansion of 
program eligibility. Florida adopted a medically needy pro- 
gram (effective mid-1986) and expanded eligibility lor 



children in Intact families, married pregnant women and 
families with an unemployed parent and their children under 
18 (effective mid-1985). South Carolina and Iowa created 
limited medically needy programs 

• Of these nine states, eight added prenatal or delivery ser- 
vices to pregnant women, and five added some type of 
coverage for certain children. 

• One state, Mississippi, delayed funding of Its recently 
established limited Medically Needy program for pregnant 
women and for children under 18. 

• Three states increased their income eligibility standards 
making it easier for more individuals to qualify for assistance. 

REIMBURSEMENT 

• In 1984, eight states authorized significant changes in their 
hospital reimbursement methodologies. 

• Five states— Pennsylvania, Ohio, Michigan, Minnesota, and 
Washington— set In motion plans to Implement new prospec- 
tive reimbursement systems for hospital Inpatient services 
based on diagnostic related groups (DRGs). Two other 
states— Indiana and North Carolina— are giving serious con- 
sideration to implementing a DRG based system for 
Medicaid. 

• Arkansas adopted an alternative inpatient hospital reim- 
bursement system. Illinois and Nebraska authorized contrac- 
ting for hospital services on a bid or negotiated basis. 

• Minnesota legislation directs the state agency to develop a 
nursing home payment system that accounts for the case 
mix. Connecticut is studying the feasibility of implementing a 
case mix reimbursement methodology for nursing homes. 

• Five states increased their drug dispensing fees, although 
Connecticut's increase was limited to the bonus pharmacists 
receive for substitution a generically equivalent drug. 

ADMINISTRATION & MANAGEMENT 

• Georgia and Connecticut adopted, Utah expanded, and 
Kansas automated a recipient lock-in program for high 
utilizers. 



Isslon certllicallon program for 
id Michigan expecls to institute 

lalory pre admission screening 



extended existing special study 
component ol the health care 
will study the concentration ot 
le Industry, and Utah is examin- 
ng competitive bidding with its 

led demonstration or pilot pro- 
atlon which establishes a alter- 
i to substitute (or nursing home 
st the cosl-eltectlvoness of pro- 

ilflcant changes in Its Medicaid 
seven prepaid health plans and 
mgemenl programs. 



WAIVERS 

• From October 1, 1981 through July 31, 1984, 47 states had 
submitted a total of 138 aplications for waivers to provide 
Home- and Community-Based Services (Section 2176). In 
that time period 44 states had a total of 76 approved waivers. 

• Over the same lime period, 24 states had submitted 82 ap- 
plications for Freedom-of-Choice waivers (Section 2175). By 
the end of July, 1984, 16 states had a total of 39 approved 
waivers. Twenty-three of fhe 34 approved waivers were for 
case-management systems, and 10 of the approved waivers 
restricted providers. Two existing waivers were renewed. 

INDIGENT CARE (from the Appendix) 

• Three stales— Georgia, South Dakota, and Oklahoma- 
made significant changes in their state indigent care pro- 
grams. For example, South Dakota's new legislation adopts a 
county catastrophic poor relief fund if 50 counties choose to 
participate by December of 1984. 

• Three slates— Colorado, New Mexico, and 
Washington— have published reports directly related to the 
issue of medical care for the indigent, and eight states are 
currently studying the issue by way of a task force, study com- 
mission, or legislative committee. 



ABBREVIATIONS 



AFOC: 


Aid to Families with Dependent Children 


IP: 


Inpatient 


AWP: 


Average Wholesale Price 


LTC: 


Long Term Care 


CMHC: 


Community Mental Health Center 


MAC: 


Maximum Allowable Cost 


CON: 


Certificate of Need 


MMIS: 


Medicaid Management Inlormation System 


DME: 


Durable Medical Equipment 


OBRA: 


Omnibus Budget Reconciliation Act ol 1981 


DRG: 


Diagnostically Related Group 


OP: 


Outpatient 


EAC: 


Estimated Acquisition Cost 


OPD: 


Outpalient Department 


EPSDT: 


Early and Periodic Screening, Diagnosis and 


PAS: 


Professional Activities Study (a survey by an in- 




Treatment 




dependent organization of hospital length of stay by 


ER: 


Emergency Room 




diagnosis and by region of participating short-term 


GA: 


General Assistance 




general hospitals) 


HID: 


Health Insuring Organization 


PSRO: 


Professional Standards Review Organization 


HMO: 


Health Maintenance Organization 


SNF: 


Skilled Nursing Facility 


ICF: 


Intermediate Care Facility 


TEFRA: 


Tax Equity and Fiscal Responsibility Act of 1982 


ICF/MR: 


Intermediate Care Facility for the Mentally 


TPL: 


Third Parly Liability 




Retarded 


UCR: 


Usual, Customary, and Reasonable 


IMD: 


Institution for Mental Disease 


UR: 


Utilization Review 



• Ohio Instituted a pro-admlsslon certification program lor 
mosl hospital admissions, and Michigan expects to institute 
one this tail. 

• Missouri adopted a mandatory pre-admission screening 
program lor nursing homes. 

OTHER 

• Nino states established or extended existing special study 
groups to examine a major component ol the health care 
delivery system. Minnesota will study the concentration of 
ownership In the nursing homo industry, and Utah is examin- 
ing the potential ol integrating competitive bidding with its 
DRQ system. 

• Four states have established demonstration or pilot pro- 
jects. Colorado passed legislation which establishes a alter- 
native care facilities program to substitute for nursing home 
care, and Washington will test the cost-effectiveness of pro- 
viding respite care. 

• Now York made some slgnlllcant changes in its Medicaid 
program. By authorizing up to seven prepaid health plans and 
up to ten physician case management programs. 



WAIVERS 

• From October 1 , 1 981 through July 31 , 1 984, 47 states had 
submitted a total of 138 aplications for waivers to provide 
Home- and Community-Based Services (Section 2176). In 
that time period 44 states had a total of 76 approved waivers. 

• Over the same time period, 24 states had submitted 82 ap- 
plications for Freedom-of-Choice waivers (Section 2175). By 
the end of July, 1984, 16 states had a total of 39 approved 
waivers. Twenty-three of the 34 approved waivers were for 
case-management systems, and 10 of the approved waivers 
restricted providers. Two existing waivers were renewed. 

INDIGENT CARE (from the Appendix) 

• Three states— Georgia, South Dakota, and Oklahoma- 
made significant changes in their state indigent care pro- 
grams. For example. South Dakota's new legislation adopts a 
county catastrophic poor relief fund if 50 counties choose to 
participate by December of 1984. 

• Three states— Colorado, New Mexico, and 
Washington— have published reports directly related to the 
issue of medical care for the indigent, and eight states are 
currently studying the issue by way of a task force, study com- 
mission, or legislative committee. 



ABBREVIATIONS 



AFDC: Aid to Families with Dependent Children 

AWP: Average Wholesale Price 

CMHC: Community Mental Heallh Center 

CON: Certificate of Need 

DME: Durable Medical Equipment 

DRG: Diagnostically Related Group 

EAC: Estimated Acquisition Cost 

EPSDT: Early and Periodic Screening, Diagnosis and 

Treatment 

ER: Emergency Room 

GA: General Assistance 

HIO: Health Insuring Organization 

HMO: Health Maintenance Organization 

ICF: Intermediate Care Facility 

ICF/MR: Intermediate Care Facility for the Mentally 

Retarded 

IMD: Institution for Mental Disease 



IP: Inpatient 

LTC: Long Term Care 

MAC: Maximum Allowable Cost 

MMIS: Medicaid Management Information System 

OBRA: Omnibus Budget Reconciliation Act of 1981 

OP: Outpatient 

OPD: Outpatient Department 

PAS: Professional Activities Study (a survey by an in- 
dependent organization of hospital length of stay by 
diagnosis and by region of participating short-term 
general hospitals) 

PSRO: Professional Standards Review Organization 

SNF: Skilled Nursing Facility 

TEFRA: Tax Equity and Fiscal Responsibility Act of 1982 

TPL: Third Party Liability 

UCR: Usual, Customary, and Reasonable 

UR: Utilization Review 



Note: 

Proposed items in ilatics 
Adopted items in standard type 



RECENT AND PROPOSED CHANGES IN 
STATE MEDICAID PROGRAMS 

July 1984 



KEY: 

Source 

G = Governor 

L Legislature 

M » Medicaid Agency 



Status 




Waiver Roguired 


C = 


Considering 


P = 


Proposed 


A = 


Adopted 


X = 


Special Session 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


ALABAMA 











• Rescinds limitation ol 6 prescriptions per 
month (MA) 

• Provides EPSDT recipients with extended 
inpatient hospital benefits for a 7 month 
period ending September 1984 (MA) 

• Directs state agency to establish a 
procedure for utilizing generic drugs 
in tilling prescriptions (HB 525) 

• Conforms state law with TEFRA of 
1982 copay exemptions (HB 764) 



• Reimburses hospital OP services at the 
lesser of a hospital's ratio ol OP cost to OP 
charges, or the rate ceiling lor all hospitals 
(MA) 

• Reimburses IP hospital at the lesser ot 
customary charges or reasonable cost per 
day, and sets limits at the comparable rale 
tor Medicare (MA) 



• Restricts provider enrollment unless the 
applicant demonstrates a need for such 
services in Ihc location oflercd (MA) 

• Limits providers to a 30-mlle radius from 
the state border (MA) 

• Grants authority to impose liens on 
property of certain recipients (HB 
793) 

• Empowers Medicaid Utilization 
Review Committee to impose civil 
monetary penalties tor violation of 
rules (HB 765) 

■ Authorizes state agency to ter- 
minate recipient's eligibility due to 
fraud or abuse, until full restitution of 
benefits wrongly received Is made 
(HB 766) 

• Strengthens fraud efforts by clari- 
fying elements of the crime (HB 392) 

• Allocates 25% of state's share In 
state lottery proceeds to Medicaid 
(HB 150) 



■ Creates a |alnl legislative committee to 
study all wcllarc, Medicaid and social pro- 
grams lit order to eliminate Inellglblcs and 
reduce overpayments (HJR 109X LA, Acl 
749 ot 1904) 

• Croates a joint legislative commit- 
tee to study the health ptunninq <inri 
Medicaid programs (SJR 34) 



ALASKA 



• Adds chiropractic and com- 
prehensive outpatient rehabilitation 
facility services (SB 510) 



• Refines existing prospective reimburse- 
ment system (MA) 

• Changes dental reimbursement to basis 
of reasonable charge, which Is 75th 
percentile of usual, customary or prevailing 
charge (MA) 

• Grants the Medical Rate Commission 
authority to establish the prospective pay- 
ment rates for the Medicaid, General Relief, 
and Catastrophic Illness programs (SB 460 
LA) 



• Subrogates rights of recipient for 
any claim from an Illness or pro- 
ceeds of an Insurance policy (SB 
424) 



• Creates Social Services Fund to 
reimburse providers recommended 
by HSAs or municipalities based on 
an annual needs assessment (SB 
484) 



2 July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


— . 

OTHER 


ARIZONA 






• Adds aptinch end lltnqimqi 
pathology sorvlcos (SB (356/ 


• hit <i<,r.ir, maximum not worth o 
rosoutcos from $30,000 to $50,00C 
(SB 1 206) 

• Exempts house equity In eligibility 
determination ot persons age 62 ano 
older (SB 1377) 


• Increases ceiling on hospital s 
reimbursement rate when no pay- 
ment is made within 30 or 60 days 
(HB 255 1) 

' Permits director ol AHCCCS to 
negotiate tor discounted hospital 
rates (HB 255/) 


• Provides director oiscrenonary power 10 
enter inlo an agreement with a contiaclor 
tot administering AHCCCS (Chap. 5, Laws 
of 1984; HB 2547 LA) 

• Limits county liability when patient 
refuses transfer after emergency 
treatment (HB 2253) 

• Requires provider to ensure 
eligibles are assigned primary care 
providers when eligibles fail to 
choose (HB 2546) 

• Directs state to promulgate a 
quality of care standard for monitor- 
ing purposes (SB 1243) 

• Requires county to issue precer- 
tification procedures for hospital ad- 
missions (HB 2153) 

• Establishes Arizona Health Care 
Cost Containment System (AHC- 
CCS) as an independent state agen- 

r-i. It-id OC^ 1 1 

cy (no (tool) 

• Establishes information required 
for determining eligibility (HB 2551) 

• Designates the county as finan- 
cially responsible for errors in 
eligibility determination (HB 2551) 

• Entitles AHCCCS to place lien on 
injured recipient's claims for 
damages (HB 2551) 

• Limits disclosure of information on 
recipient's financial status (HB 
2551) 




ARKANSAS 






" Limits IP hosplliil slays nut IP physician 
visits lo 9 clays liom 2/13/84 to 6/30/84 
(MA) 

• Rescinds the decision lo eliminate ex- 
tended IP hospital and IP physlclnn visit 
benefits lo EPSDT tcclplcnls (MA) 

• Limits IP hospital days to 50th petccntlle 
with a 35 day limit per fiscal year. Exten- 
sions will be considered lot EPSOT chlldtco 
(effective 7/1/B4) (MA) 

• Covets psychological testing only when 
provided In a certified community mental 
health center (MA) 




• Replaces S196 per diem payment lor 
oul-ot-slale hospilals with 68% ol charges 
MA) 

• Reimburses hospitals at 80% of 
Medicaid pet diem in effect 1/1/84 and 
eliminates cost settlements (MA) 

• Incteases drug dispensing lee to S3. 87 
MA) 

1 Establishes a prospective payment 
ystem utilizing per diem rates based oo 
he hospital s cost data (MA) 


• Adopted UB-82 uniform claim form lor 
several providers (MA) 

• Requires prescription claims to include ID 
number for UR purposes (MA) 

• Categorizes hospital OP services into: 
emergency services; surgical procedures; 
nonemergency services; and therapy 
reatment services (MA) 

• Develops a list ol surgical procedures 
which may be performed on an OP basis. 

nd requires prior authorization tor all other 
>urglcal procedures (MA) 


continued 



July 1984 3 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


CCCDDTC T(l IMPflHUF 

t rrUn 1 o IU imrnuvc 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


ARKANSAS continued 


• Ends classification of boarding homes as 
an institution, and makes Medicaid 
residents eligible for home health services 
(MA) 

• Limits OP services-which includes non- 
emergency hospital, physician office and 
nursing home visits-to 12 per year, with 
certain exceptions permitted (MA) 

• Limits lab and x-ray services to $300 
per year, with certain exceptions permitted 
(MA) 

• Limits physician IP hospital visits to one 
per day (MA) 




• Prohibits fractional billing for personal 
care services (MA) 


* Issues ID cards to recipients (SB 
205) 




CALIFORNIA 


• Adds external prostheses, pros- 
thetic implants and reconstructive 
surgery incident to mastectomy 
when deemed medically necessary 
(AB 2440) 

• Mandates SNFs/ICFs provide 
basic laundry and haircutting ser- 
vices without charge (AB 2613) 

• Directs state to increase maximum 
limit of reimbursable days for IP 
psychiatric services for minors (AB 
2676) 

• Adds coverage of intermediate 
care facilities for chronically or ter- 
minally ill children (AB 3005) 

• Extends coverage of perinatal ser- 
vices when delivered in a coor- 
dinated manner (AB 3021) 

• Covers diagnosis and treatment of 
Alzheimer's Disease (AB 3155) 

• Limits long-term facility claim for 
personal services to 20% of per- 
sonal needs allowance (AB 3264) 

• Establishes $45 as the minimum 
allowance for personal needs and 
permits facilities to charge '/a of the 
allowance for personal laundry (AB 
3627) 

" Covers advanced life support 
medical transportation when prior 
authorized (AB 3649) 


• Permits denial of AFDC aid for ap- 
plicants failing to provide social 
security number (AB 1630) 

• Exempts from eligibility determina- 
tion S45 per month for recipient s 
personal needs in a SNF/ICF (AB 
2613, AB 2845) 

• Allows certain transfer of assets 
for married recipient living separate- 
ly from spouse and requires notifica- 
tion of the policy to the individual 
and spouse (AB 2615) 

• Limits annual cost-of-living ad- 
justments under AFDC and SSP (for 
aged, blind and disabled) grants to 
those provided by the budget act 
(AB 3077) 

• Makes individuals with multiple 
sclerosis eligible for Medi-Cal (AB 
3209) 

• Extends income exemption for the 
amount paid toward in-home sup- 
portive services to medically needy 
individuals (AB 3398) 

• Requires agreement in division of 
community property for individuals 
residing in SNF/ICF who wish to 
have property deemed transferred 
(SB 2073) 

• Limits AFDC and SSI cost-of-living 
increases to 2% (SB 1379) 


• Increases reimbursement to physicians 
and dentists by 7.5% and most other 
noninstltutlonal providers by 3% (LA) 

• Increases budget for noncontract 
hospitals by 10% (LA) 

• Limits Medi-Cal contracting 
hospital billing a prepaid health plan 
for IP emergency services to the 
hospital's rates established under its 
Medi-Cal contract (AB 950) 

• Reimburses IP intensive rehabilita- 
tion hospitals for vacant accomoda- 
tions during temporary absences of 
up to 2 days (AB 1208) 

• Requires providers to collect 
copay and reduces reimbursement 
by the amount of the copay (AB 
2314, SB 2242 and SB 1379) 

• Increases reimbursement rates for 
noninstitutional providers by 10% 
(AB 2928) 

• Establishes a per diem rate of 
$40.51 per patient for adult day 
health services, and directs the state 
to establish a rate structure for FY 
85-86 (AB 2990) 

• Removes cost-of-living ad- 
justments to County Health Services 
Fund payments and replaces with 
adjustments reflecting the Budget 
Act for FY 84-85 (SB 1379) 


• Delays Implementation of 18-month 
deadline tor counties to submit claims for 
costs until 1/1/85 (AB 448 LA, Chap 235 
ot 1984) 

• Transfers authority to negotiate 
exclusive Medi-Cal contracts from 
Medical Assistance Commission to 
Dept ot Health Services (AB516.SB 
667) 

• Prohibits long-term facilities from 
discriminating against patients bas- 
ed on source of payment (AB 2261. 
SB 1346) 

• Requires facilities to Inform ap- 
plicants tor admission whether the 
facility participates in Medi-Cal and 
the facility's policy on involuntary 
transfers (AB 2261) 

• Prohibits denial of services due to 
Inability to pay copay (AB 2314) 

• Requires biannual submission to 
Department of Finance of Medi-Cal 
program assumptions and estimates 
(AB 2314, SB 1379) 

• Directs the promulgation of stan- 
dards for controlling county eligibility 
determination costs (AB 2314) 

• Allows suspension of provider 
convicted of a felony prior to final ap- 
peal (AB 2366, AB 2842) 


• A voter initiated referendum, Pro- 
position 41, shall be considered by 
the electorate on Novermber 7, 
1984. Proposition 41, would limit 
California 's public assistance expen- 
ditures (such as Medi-Cal, AFDC, 
and Family Planning) to 1 10% of the 
per capita average of the other 49 
states. A public assistance commis- 
sion would be established to survey 
the state data, and make recom- 
mendations to the legislature prior to 
the July 1, 1986 implementation 
date. 

• Urges alternative rate hospital and 
group health contracts be exempt 
from federal anti trust provisions (AB 
707) 

• Requires state to report to 
legislature on the number ot 
hysterectomies pedormed on Medi- 
Cal recipients (AB 3706) 

• Studies the access problems en- 
countered by the disabled in the 
Medi-Cal program (AB 3835) 

• Establishes Community Care 
Facility Demonstration Project for 
the Elderly to place elderly in a com- 
munity setting (AB 3900)' 

continued 



July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 

ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


CALIFORNIA continued 




• Allow:, rmymantr. for htni huhi; tot 
up to 5 days (SB 1661) 

• Covers heart and honrt-lung 
transplants In hospitals npprovod tor 
such procedures (SB 1967) 

• Covors bono marrow transplants 
and oihor experimental procedures 
for the troatmont of cancer (AB 
3266) 

• Increases the tallowing copays; 
ER from $6 lo $w and prescriptions 
from $l to $2 whan the prescription 
Is $10 or moro. Imposos $2 copay 
on medical transportation, modlcal 
equipment, and home health. Ex- 
pands copay exemptions from rock 

pH'ntu untlei aqo !.' M umfei m/o III 
(AB 2314, SB 1379 and SB 2242) 

• Expands copay oxomptlons to 
women rocoivlnq perinatal cum (An 
2314) 


• Umitt the amount of recipient's In 
como that must bo obligated to 
medical oxponses prior to eligibility 
to ono month when services are 
rocoivod during 14-day period 
overlapping two months (SB 2174)* 


• r xpressly provides that stale may 
recover increased cost of health 
facility reimbursement due to 
negligence (AB 2258) 

• Limits increases In prescription 
drug payments to those provided in 
the budget act (AB 3077) 

• Increases rate of payment tor OP 
services to hospitals serving a 
disproportionate share of low- 
income persons (AB 3156) 

• Exempts certain rural hospitals 
who receive fee-tor-service 
payments from the rate per 
discharge limitation (AB 3162) 

• Restricts reimbursement rates of 
FY 84-85 to the June 1984 rates as 
adjusted for cost-of-living or by the 
legislature (SB 1379) 

• Sets maximum reimbursement 
rate for long-term care in a hospital 
at the same level as maximum for 
feestanding SNF/ICFs (SB 1931) 

• Provides unspecified increase in 
reimbursement to long-term care 
facilities tor wage, staffing and train- 
ing cost increases (SB 1661) 

• Permits contracting with small and 
rural hospitals tor IP and OP hospital 
services (SB 1458) 

• Requires MedkCal negotiator to 
consider a county hospital's bad 
debts, medical education and 
capital needs during negotiations 
(SB 2092) 

• Mandates acuity-based reim- 
bursement system for long-term 
care (SB 1661) 

• Adds services of nurse practi- 
tioners who bill independently in a 
SNF/ICF (AB 3133) 

• Allows contracts with small and 
rural hospitals be entered on a non- 
bid basis (SB 1458) 

• Requests a plan to provide physi- 
cians with the option of income tax 
deductions in lieu of MedkCal 
payments (AB 3179) 


• Establishes penalties for in- 
dividuals submitting false hospital 
cost reports (AB 2366) 

• Authorizes in-home services for 
ventilator-dependent children pro- 
vided by a licensed community care 
facility (AB 2852) 

• Extends period of time for claims 
submittal from 2 months to 6 months 
(AB 2976) 

• State must provide toll-free 
number 24 hours a day for providers 
submitting prior authorization re- 
quests (AB 3055) 

• Excludes from state reimburse- 
ment the costs to counties in issuing 
regulations (AB 3281) 

• Creates Medical-Surgical 
Therapeutic Advisory Committee to 
review experimental procedures tor 
possible MedkCal coverage (AB 
3349) 

• Requires beneficiary to sign and 
date MedkCal card upon receipt (AB 
3532) 

• When a recipient abuses services 
while on restricted status, the state 
may restrict the individual to receiv- 
ing care through one provider (AB 
3533) 

• Requires unpaid payments to 
SNFs. ICFs and ICFs/DD bear in- 
terest (AB 3458) 

• Prohibits payment for medical 
transportation when ordering physi- 
cian has an interest in the company, 
unless previously disclosed (AB 
3768) 

• Extends exemptions of children's 
hospitals from MedkCal provider 
contract provisions until 7/1/86 (AB 
3849) 

• Eliminates prior authorization re- 
quirement for treatment, supplies, or 
equipment which costs under $100 
(AB 3888) 

• Creates MedkCal Therapeutic 
Drug Utilization and Review Com- 
mittee to develop a drug UR system 
(AB 3888) 


• Requests a waiver to provide 
guaranteed eligibility of at least six 
months for persons receiving 
perinatal services (AB 3021)' 

• Directs a study of potential Medi- 
Cal savings in dental care costs if a 
greater number of Californians 
received fluoridated water (ACR 25) 

• Exempts hospitals that have not 
been awarded a MedkCal contract 
from certain community access re- 
quirements under the state finance 
authority (SB 419) 

• Develops a consumer information 
system for providing information on 
long-term health care facilities and 
creates the Long-Term Health Care 
Advisory Board (SB 1661) 

• Requires minimum staffing ratio of 
1 staff for every 2 clients in ICF/DD 
habilitation facilities (SB 1878) 

• Requests a freedom of choice 
(2175) waiver to implement the 
state's Expanded Choice of Health 
Care Plans program (MP) ' 

• Urges alternative rate hospital and 
group health contracts be exempt 
from federal anti-trust provisions (AB 
707) 

• Creates MedkCal Open Drug For- 
mulary as two pilot projects which 
would reimburse for any FDA ap- 
proved drug (AB 2655) 

• Establishes the County Health Ser- 
vices Fund, which would be funded 
by the federal government via pilot 
projects to improve access (AB 
3156)' 

• Provides for the testing and im- 
plementation of the Capitated Health 
Systems Program which would con- 
tract with providers and insurance 
carriers for Medi-Cal services on a 
capitated basis. By 1/1/87 contracts 
shall be entered into in 2 
geographical areas containing at 
least 20% of state MedkCal popula- 
tion (AB 516, AB 1515, SB 667) 

continued 



July 1984 5 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


PHI IPIFS AFFFTTINd 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


CALIFORNIA continued 














• Requires tho phono number for 
meowing prior authorization bo ac- 
cossable 24 hours a day and that 
recipients bo provided with informa- 
tion on appealing donials. Also ro- 
quires a list of otyactvo medical 
criteria which will automatically 
qrant any roquost mooting the 
criteria (AB 3089) 

• Exempts cortain small hospitals 
from separate llconsure re- 
quirements for SNF/ICF care (AB 
669) 

• Makes counties liable for over- 
payments made prior to 7/1/82 (SB 
823) 

• Payments on a capitation or 
prepayment basis must be paid 
within 30 days of submission (SB 
746) 

• Restricts source of funding for 
abortions to the special financing 
fund (SB 1379) 

• Transfers federal and specified 
county funds received for expen- 
ditures of prior fiscal year from 
General Fund for future Medl-Cal 
deficits (SB 1379) 

• Requires county bear nonfederal 
share of county-referred state 
eligibility determinations (SB 1379) 

• Exempts contracting hospitals 
from submitting a uniform cost 
report (SB 1401) 

• Permits recognizing one entity to 
represent small and rural hospitals 
(SB 1458) 

• Requires long-term care facilities 
to state Its policy on private pay pa- 
tients converting to Medl-Cal (SB 
1661) 

• Allows moratorium on Medl-Cal 
admissions to long-term care 
facilities which do not meet certifica- 
tion conditions (SB 1661) 

• Permits submission of claims by 
electronic means (SB 1842) 


• Establishes tho County Health Sor- 
vices Fund, which would bo funded 
by tho federal government via pilot 
projects to improve access (AB 
3156)' 1 

• Provides for tho testing and im- 
plementation of tho Capltatod Hoalth 
Systoms Program which would con- 
tract with providors and insurance 
carriers (or Modl-Cal sorvicos on a 
capitatod basis. By 1/1/87 contracts 
shall bo ontored Into In 2 
geographical areas containing at 
least 20% of state Medl-Cal popula- 
tion (AB 516, AB 1515, SB 667) 

• Requires state to report to 
legislature on the number of 
hysterectomies perlormod on Modi- 
Cal roctpients (AB 3706) 

• Studies tho access problems on- 
countered by the disablod in tho 
Medi-Cal program (AB 3835) 

• Establishes Community Care 
Facility Demonstration Project for 
the Elderly to place elderly In a com- 
munity setting (AB 3900)' 

• Dlrocts a study of potential Medl- 
Cal savings In dental care costs If a 
greater number of Calllornians 
received fluoridated water (ACR 25) 

• Exempts hospitals that have not 
been awarded a Medi-Cal contract 
from certain community access re- 
quirements under the state finance 
authority (SB 419) 

• Develops a consumer Information 
system for providing information on 
long-term health care facilities and 
creates the Long-Term Hoalth Care 
Advisory Board (SB 1661) 

• Requires minimum staffing ratio of 
1 staff for every 2 clients in ICF/DD 
habituation facilities (SB 1878) 

• Requests a freedom of choice 
(2 1 75) waiver to implement the 
state's Expanded Choice of Health 
Care Plans program (MP) ' 

continued 



6 July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
REIMBURSEMENT 


POLICIES AFFECTING 
ELIGIBILITY 


brrUn I o iu imrnuvc 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


CALIFORNIA continued 
















• Extends notification for contrac- 
ting with prepaid health plans from 
30 days to 60 days (SB 2215) 

• Deletes sunset provision for law 
requiring the issuance of Medi-Cal 
cards to individuals investigating 
fraud (SB 2315) 

• Clarifies utilization control exemp- 
tions lor prepaid plans (AB 3117) 

• Clarifies appeal procedures for 
adverse administrative decisions 
(AB 3117) 

• Makes use of a Medi-Cal card 
other than the recipient's own a 
misdemeanor (AB 3530) 

• Clanlies ''medically necessary" 
lor justifying the rendering of ser- 
vices (AB 3887) 

• Makes impersonation of Medi-Cal 
beneficiary in order to obtain ser- 
vices a misdemeanor (AB 3530) 

• Requires DME purchased tor a 
recipient be returned when no longer 
medically necessary (SB 1967) 

• Permits adjustments in payments 
to providers facing bankruptcy or 
discontinuing services (SB 2316) 

• Replaces state family planning 
services program with a county 
assistance program (SB 1450) 

• Authorizes access to financial ac- 
count numbers when investigating 
recipient abuse (SB 3531) 

• Makes it a crime to willfully or 
knowingly fail to disclose certain 
facts during eligibility determination 
(AB 3982) 

• Requires agency to issue press 
releases when enforcement actions 
are taken against LTC facilities (AB 
3264) 

• Requires LTC facilities to inform 
recipients of charges for services 
payable by the resident (AB 3264) 

• Prohibits claims against a dece- 
dent's estate of a recipient aged 65 
and over, for the period prior to 
June, 1981 (AB 3096) 





July 1984 7 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 

MUlYIINIo 1 It H 1 11 MM 

& MANAGEMENT 


OTHER 
STRATEGIES 


COLORADO 


• Adopted cost sharing provisions (HB 
1434 LA) 

• Eliminates non emergency surgery 
and prescribed drugs as covered 
services (HB 1440) 




• Reduces trom 50% to 25% the state 
share for reasonable costs of nursing home 
administration, property, and room and 
board that exceed actual cost (HB 1435 
LA) 

• Reimburses providers (from 7/84 
through 12/64) at the Medicaid or 
Medicare rates, whichever Is lowest (HB 
1437 LA) 

• Reduces payment to nursing homes lor 
reasonable cost of hcallh care services 
and food from 100th percentile to 90ih 
percentile (HB 1438 LA) 


■ Prohibits denial ol health Insurance 
benefit payments lo individuals eligible tor 
Medicaid (HB 1192 LA) 

• Reserves spoclal hinds to aid 
AFDC-U families (HB 1439) 


• Establishes n pilot program tor develop- 
iiO "allcinatlvc care facilities" as an allcr- 
lullvo to nursing home care (SB 206 LA) 

• Establishes family members as 
rosponslblo for costs incurrod by 
recipient of lonq-torm caro services 
(HB 1319) 

• Exempts oxporimontal programs 
under Medicaid from HMO regula- 
tions (SB 129) 

• Crootos a health care cortlflcato 
system tor the purposo ol purchas- 
ing health insuranco (HB 1380) 

• Applied for homo- and community- 
basod sorvlcos waiver (2178) to pro- 
vide porsonal care, case manage 
ment and similar services (Model 
waiver) (MP) ' 


CONNECTICUT 


• Increases personal allowance lor reci- 
pients in nursing homes and state institu- 
tions from S28 to S30 per month (HB 5195 
LA; Act 84-354 ol 1984) 

• Repeals copay (S.50) for medical 
transportation (SB 359 LA; Ac) 84-167 of 
1984) 

• Adds adult day care (HB 5083) 

• Reimburses adult day care 
centers for services in cities where 
elderly population is greater than 
15.000 (HB 5211) 

• Adds liver transplant (HB 5010) 

\Medicaid Cost Containment Study 
Commission recommendation 


* Increases AFDC standard of need by the 
urban consumer price index (HB 5191 LA; 
Act 84-470 of 1984) 


• Increases dispensing lee bonus from 
$.25 to $.50 tor substitution with a 
genetically eguivalent drug (SB 358 LA, 
Act 84-217 of 1984) 

• Allows the establishment of a separate 
rate for traumatic brain Injury patients not 
requiring acute hospllal care (HB 5273 LA; 
Act 84-360 of 1984) 

• Directs agency to contract with providers 
capable of providing care and rehabilitation 
for traumatic brain injury (HB 5273 LA) 

• Allows state agency to develop a 
hospllal payment system based upon 
reasonable costs of an efficient and 
economically operated facllily (HB 5226 
LA) 

• Modifies paymenl for administratively 
necessary days to: 50% of actual costs for 
the first 7 days; 75% of costs for the next 
7 days; and 100% of costs thereafter (HB 
5226 LA)f 

• Directs commissioner to study modilylnc 
the nursing home rate setting formula It 
account for case mix; report due 2/86 (SB 

m i A) 


• Directs the development of a lock out 
proposal by 11/30/84 lor review by the 
Medicaid Cost Containment Study Commis- 
sion (HB 5157 LA)| 

• Mandates a physician and pharmacy 
"lock-In" program, with a report on Im 
plemcntatlon due 10/85 (HB 5155 LA; Ac 
84-352 ol 1984)t 

• Requires nursing homes to maintain a 
dated and accessible list ol admission ap 
plications (HB 5761 LA, PA 84-245 o 
1984) 

• Suspends providers license lor fraud In 
the Medicaid, or other assistance programs 
(SB 355 LA, Act 84-235 ol 1984) 

• Prohibits health Insurance policies from 
denying benefits to an Individual who is 
eligible lor Medicaid (HB 5226 LA) 

• Establishes Medicaid as payor ol las 
resort (HB 5227 LA) 

• Requires annual cross match o 
public assistance and Medicaid reel 
plants with financial institutions (HE 
5270) 


• Establishes a pilot pioqiam which 
dedicates stall to cllglblllly determination 
lor hospitalized applicants In need ol nuis- 
inq home care (HB 5191 LA; Act 84-39 ol 
1904) 

• Received home and community-based 
services waiver (2716) lo provide case 
management services (MODEL WAIVER) 
(MA) 

• Establishes a commlllec to study Indices 
for the Increasing ol asslslance paymenls 
(HB 5191 LA; Act 84 360 ol 1984) 

• Extends life of Medicaid Cost Contain- 
ment Commission to 1/85 and adds other 
issues to be addressed (HB 5154 LA; Act 
B4-29 0l 1964)t 

" Establishes a capitated primary 
care case management study to 
coordinate the delivery of services 
by individual practloners (MC) 

continued 



8 July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVF 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


CONNECTICUT continued 












• Establishes administratively 
necessary day payment rate equal 
to 150% of mean rate for type of 
facility providing level of care re- 
quired by recipient (HB 5158ft 

• Creates separate rate of reim- 
bursement for nursing homes with 
recipient requiring extensive care, 
but at a level lower than Inpatient 
hospitals (HB 5273) 

• Reimburses community health 
centers tor full cost of dental, mater- 
nity, and mental health benefits (HB 
5274) 

• Directs department to establish 
cost-based fee system for certain 
OP clinic services (HB 5408) 

• Reduces reimbursement for ad- 
ministratively necessary day to the 
amount paid to facilities providing 
level of care needed by recipient (SB 
220) 

• Adjusts nursing home reimburse- 
ment to cover Increased costs due 
to state or federal regulatory 
changes (SB 354) 

• Separates nursing and ad- 
ministrative costs associated with 
nursing pools when reimbursing nur- 
sing homes (SB 357) 

• Requires cost of education for nur- 
sing home employees to be con- 
sidered in setting reimbursement 
rates (SB 360) 


• Increases funding for fraud in- 
vestigation (SB 10) 

• Bring state reimbursement appeal 
proceedings into compliance with 
federal regulations by eliminating 
binding arbitration (SB 225) 

• Extends time limit for requesting 
hearing on a rate decision (SB 353) 

• Appropriates funds to attorney 
general for investigation of provider 
fraud (SB 10) 

• Transfers administration of the 
Medicaid program to a newly 
created Department of Human 
Responsibilities (HB 5009) 

• Creates a pilot preadmission 
screening program for applicants to 
long term care facilities; report on 
the program is due 10/85 (HB 5160, 
HB 5759ft 


• Establishes pilot program to con- 
tinue eligibility (or six months after 
recipient becomes ineligible for 
AFDC (HB 5205) 

• Requires commissioner to study 
feasibility of implementing a single 
nursing home rate for Medicaid and 
self-pay patients (SB 222) 

• Establishes pilot program to 
recoup assets that were transferred 
in order to be eligible tor Medicaid 
(HB 5156ft 

• Studies the feasibility of providing 
Medicaid recipients transportation 
to and from physicians ' offices and 
hospitals (HB 5531) 

• Directs commissioner to apply tor 
home- and community-based waiver 
(2176) to provide case manage- 
ment, respite care, day care and 
other similar services to prevent in- 
stitutionalization of elderly and 
disabled persons (SB 27)' 

• Establishes pilot program, in one 
geographic area of the state, (or 
reimbursing adult day care services 
(2176 waiver request) (SB 224)' 


DELAWARE 






• Provides pre natal care lo pregnant 
women who would otherwise be eligible II 
the child had already been born, effective 
7/1/B4 (MA) 


• Excludes from nursing home reimburse- 
ment all costs related to sale, acquisition 
or refinancing (MA) 







July 1984 9 



POLICIES AFFECTING 
BENEFITS 


pni trice AFFFPTIMP. 
ELIGIBILITY 


Dfll IP1CC ACECPTIklP 

REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


DISTRICT OF COLUMBIA 










• Adds medical day treatment services (in- 
tensive therapeutic programs) (or adults 
and children under age 3 (MA) 




• Continues spending cap lor IP hospllal 
reimbursement with the new figure at 
$100.8 million (MA) 


• Prom ul [jilted new um| illations ilolmeainui 
procedures and grounds for suspension 
and tcrmlnallon of providers for reasons of 
fraud, abuse, and misuse (MA) 




FLORIDA 


• Covers podiatry services (MA) 


• Adds Ribcoff children, children under 21 
in an intact family effective July 1985 (SB 
176, SB 697 LA) 

• Adds eligible, married, pregnant women 
(SB 176, SB 697 LA) 

• Adds AFDC U families effective July 
1985 (SB 176, SB 697 LA) 

• Establishes Medically Needy Program to 
provide services the categorically needy 
are entitled to except long-term instu- 
lionalized services (SB 176, SB 697 LA) 
•Increases income limit to $814 per 
month lor instilutionalized recipients (MA) 


• Increases OP hospital services cap from 
$100 to S500 cffecllve July 1984 (SB 
176, SB 697 LA) 

• Implements comprehensive OP 
surgery plan which includes OP pay- 
ment tor certain surgical procedures 
(MP) 


• Deposits the 1% asscsmcnl (which In- 
creases to 1.5%) on hospital operating 
revenue In the Public Medical Assistance 
Trust Fund which funds the new expansion 
In olcglblllty (sco clcglblllty column) (SB 
176, SB 697 LA) 

• Authorizes the use of $10 million from 
the Public Medical Assistance Trust Fund 
to establish primary care lor low-Income 
persons through the county public health 
units (SB 176.SB 697 LA) 

• Transfers UR Irom local Medicaid offices 
to nursing care facilities, with certain ex- 
ceptions (MA) 

• Requires hospitals to submit 
itemized bills to recipients (SB 726) 

• Requires counties to participate in 
reimbursement of hospital OP ser- 
vices costs between $1 00-$ 1000 
(HB 673) 

• County must accept state's 
designation ot a recipients county of 
residency unless proven otherwise 
by that county (HB 673) 

• Authorizes competitive bidding 
and negotiation tor IP/OP services, 
with goal that all such services be 
provided under contracts by July 
1988 (HB 814) 

• Mandates nursing homes not 
meeting their proportionate share of 
Medicaid recipients must admit pa- 
tients by order of date of application, 
until share is met (HB 860) 

• Requires community mental 
health centers to be primary point of 
entry for psychiatric care under 
waivers (MP) 


• Conducts a study to reduce Institutional 
core costs by actlvlllcs Including expan- 
ding existing 2176 waivers nnd targeting 
preadmission screening, ellorts (LA) 

• Requires SNFs/ICFs to moot pro- 
portionate share of Medicaid reci- 
pients (25% of capacity or a share 
dotormlned by HSA) prior to CON or 
licensure approval (HB 860) 

• Applied for 2 homo- and 
community-based services waivers 
(2176) to: provido case manage- 
ment, personal care and health sup- 
port services to rosidonts ot the Gulf 
Home Alternative Living Plan Pro- 
tect; and provide case managoment, 
respite care and 6 other services to 
medically depondent elderly requir- 
ing ICF/SNF level ot care (MP)- 



10 July 1984 



POLICIES AFFECTING 
hf wrr itc 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


GEORGIA 






• Increases personal noods 
allowance trom $2I> in $40 (SB 320) 


• Provides lull range ol services to 
medically needy pregnant women, 1o 
medically needy depilved children, and to 
children receiving foster care services o 
adoption supplements (GA) 




• Allows supplementation lor private room 

Of pflVdie SlIIci Till let.l[Jieina ill o nuumi 

home (HB 1235 LA) 

• Provides single source contract for the 
construction ol eyeglasses (MA) 

• Establishes a lock-in program lor certain 
recipients (MA) 

• Enrolls recipients in HMOs (MP) 

• Creates a hospital preadmissions 
review program and a seconc 
surgical opinion program for 
selected procedures (MC) 


• Requests Congress and DHHS to in" 
crease personal needs allowance minimum 
to S35 per month (SR 332 LA) 


HAWAII 




• Adds sterilization procoduros IHB 
140) 

• Covers experimental modlcal pro- 
coduros when cortaln criteria are 
met and Imposes limit ol $600. 000 In 
state funding tor such procoduros 
(MB 2185) 

• Adds porsonnl cam sorvlcos with 
a funding limit of .5 million (MP) 


• Roquosts a rovlow tor Increasing 
Income eligibility standards (HCR 
66) 

• Amends medically neody eligibility 
rogulntlons to conform with TEFRA 
(MC) 


• Studies feasibility ol reimbursing lor 
cluneal social workers (SR 143 LA) 


• Increase TPL efforts (HB 326 ) 

• Establishes procedural 
safeguards for provider audits (HR 
151) 

• Obtains single source providers 
for prescription drug and dental pro- 
grams (MC) 

• Develops a medical assistance 
recovery chapter within the rules to 
enable recovery of misspent funds 
(MP) 

• Develops a UR committee for 
prescription drugs (MC) 


• Initiates a Psycho social Intervention Pro- 
ject to demonstrate Ms effectiveness in 
reducing excess utilization (MA) 

• Requests a study of limiting reci- 
pient's freedom of choice (HCR 10) 

• Requests a study on implementing 
a relative responsibility law (HR 54) 

• Requests a review of income 
eligibility standards (HR 77) 

• Requests a study of allowing 
private foundations to receive dona- 
tions for payment of organ 
transplants (HR 55) 

• Urges state agency not to utilize 
funds for abortion (HCR 38, SCR 8) 

• Studies feasibility of contracting a 
private entity to administer the 
Medicaid program (HR 152) 

• Studies the impact of recent 
reductions in provider reimburse- 
ment on providers and recipients 
(HR 162) 

• Studies the feasibility of utilizing 
existing sources to identify 
unreported recipient assests and in- 
come (HR 272) 

• Studies the feasibility of transferr- 
ing the Medicaid program to an 
autonomous unit (HR 334) 



July 1984 11 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


IDAHO 


• Eliminates all solid organ transplants ex 
cept kidney and liver when prior authorized 
(MA) 

• Covers swing beds in hospitals where no 
nursing home (SNF) beds are within 50 
miles (MA) 

• Adds ambulatory surgical center 
coverage (MP) 




• Subjects allowable properly costs to In- 
vestment limitation (HB 589 LA) 




• Ends family responsibility program In 
long term core (MA) 

• Repeals family responsibility pro- 
gram (SB 1222) 

• Rovlsos determination process of 
family responsibility program (SCR 
120) 

• Appliod for home- and community- 
based waiver (2176) to provldo per- 
sonal care services to Individuals In 
nursing homes (MP)" 

• Enforces the responsibility of 
parents tor minor children and ot 
spouse tor spouse, and recoups 
Medicaid payments (MP) 


ILLINOIS 


• Provides a $50 monthly grant to 
persons eligible for SSI and residing 
in a hospital, SNF, ICF or extended 
care facility (HB 2484) 


• Eligibility is precluded if applicant 
is eligible for refugee aid (HB 3080) 


• Provides tor negolated rates for hospital 
services (SB 495 LA) 

• Negolates a higher payment lor bone 
marrow and organ transplants, with a limit 
ot 60% ol UCR charges (MA) 

• Adds real estate taxes and deletes 
profits in determining SNF/ICF pay- 
ment rates (HB 2947, SB 1779) 

• Includes ICF/MR and SNF for 
pediatrics In promulgating new pay- 
ment conditions for ICFs/SNFs (HB 
2468) 

• Authorizes the splitting ot payment 
for IP hospital services between two 
fiscal years (HB 3082) 

• Makes increase in SNF/ICF rates 
retroactive to July 1, 1983 (HB 2350) 

• Establishes rules governing clinic 
and outpatient hospital services (SB 
1499) 

• Implements prepaid capitation 
programs for dental, IP hospital, am- 
bulatory and full services (except 
dental and optemetrlcs) (MP) 


• Waives provisions ot the open meetings 
act lor negotiating contracts wllh hospitals 
(SB 495 LA) 

• Implements slate-wide uniform billing 
procedures (UB-82 claim lorm) eltccflvc 
1/1/85 (SB 495 LA) 

• Establishes an acquisition cost list 
for prosthetic devices, drugs, den- 
tures, eyeglasses and other medical 
Items (HB 2946, SB 1739) 

• Creates the Illinois Health Care 
Cost Containment System to 
develop pre-paid contracts for acute 
care services (SB 1530) 

• Abolishes Medicaid Fraud Study 
Commission (SB 1902) 


• Creates Health Care Cost Conlalnmenl 
Council to collect hospllal data and develop 
cost conlalnmenl strangles (SB 495 LA) 

• Establishes goal ot limiting hospital price 
Increases to the general Inflallon rale (SB 
495 LA) 



12 July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


INDIANA 










• Adds prognant women who woulc 
bo ollglblo If tho child had already 
boon bom (HB 1141) 

• Hequlros annual review ol ICF/MR 
residents to verity continued neac 
lor sorvlcos (SB 144) 

' Adds AFDC-U (SB 100) 
" Extonds 6 month eligibility to 
recently unemployed Individuals los- 
ing Insurance covorago (SB 347) 




• Transfers responsibility (or administering 
preadmission nursing home screening to 
Department of Aging and Community Ser* 
Vices (HEA 1203 LA) 

• Establishes guidelines lor admitting in- 
dividuals to nursing homes without pread- 
mission screening (HEA 1203 LA) 

■ Requires a study of the preadmission 
screening program and of services needed 
to improve in-home care (HEA 1203 LA) 

• Authorizes state agency to enter 
into contracts for the administration 
of the program (HB 1413) 


• Expands HMO contracts to statewide for 
AFOC recipients (MA) 

• Requests a home- and 
community-based waiver (2176) to 
provide alcohol and drug abuse ser- 
vices to individuals under id (SB 
429)' 

• Establishes family responsibility 
for sharing the costs of long-term 
care (SB 162) 


IOWA 


• Covers curtain prescribed over-the 
counler drugi (SF 236 LA) 


• Creates medlcnlly needy program lor 
pregnant women and tor children under trie 
age ol 21 (SF 2351, SF 2363 LA) 


• Increases provider rates by 4%-2.fl% 
restoration ol across-the-board reduction 
and Increase ol 1.2% (SF 2351 LA) 

• Increases ICF [pimburscmEnl rate to 
bbth percentile (SF 2351 LA) 

• Limits dispensing fee for brand 
name drugs to 90% of fee tor 
generic drugs with certain execp- 
tlons (HB 1533) 


• Authorizes a drug utilization review pro- 
gram (SF 2351 LA) 


• Requests freedom-of-choice waiver 
(2175) to allow the agency to enter into 
contracts with cost-effective providers (SF 
2351 LA)* 

• Studies the feasibility of establishing a 
special ICF category to provide 
rehabilitative services to individuals suffer- 
ing from brain injuries (SF 2351 LA) 

• Received home- and community-based 
services waiver (2176) to provide 
homemaker, home health aide/personal 
care, adult day care and residential treat- 
ment services to blind and disabled reci- 
pients (MODEL WAIVER) (MA) 

• Applied for 3 home- and 
community-based waivers (2176) to 
provide: case managaement. OP, 
work activity and other services to 
chemically mentally ill age 18-20; 
habilitation, homemaker /home 
health aide, and similar services to 
mentally retarded and developmen- 
tal^ disabled individuals; and case 
management, adult day care, 
respite care and in-home 
psychological services to the elderly 
(MP)' 

• Urges declaration of 1 year 
moratorium on all hospital construc- 
tion (SJR 3) 



July 1984 13 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
RFIMRHRSFMFNT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 

*5TRATFRIF<; 
o i mm i L.iiir o 


KANSAS 










• Limits physician office visits to 12 per 
year (MA) 

• Covers only nonelecllve surgery. (MA) 

• Expands copay requirements to include: 
$10 per OP hospital visit; $10 per am- 
bulatory surgical center visit; and $25 per 
visit to an out-of-state IP treestanding 
psychiatric facility (MA) 


• Adopts SSI income and resource provi- 
sions for SSI related groups (MA) 


• Prohibits reimbursement to now owners 
ol existing adult care homes prior to 
relicensure (MA) 

• flewses reimbursement 
methodology for hospital OP ser- 
vices (MP) 


• Permits adult care homos to establish 
private pay wings (MA) 

• Increased TPL efforts (MA) 

• Automated recipient lock-In program 
(MA) 




KENTUCKY 


• Covers medications essential for 
avoiding hospitalization, through the Drug 
Pre-Authorization Program (MA) 

• Defines gastric bypass surgery and other 
similar procedures as cosmetic and 
therefore nonreimbursable unless criteria 
are met (MA) 

• Mandates copays on physician, 
IP, OP, primary care and ER ser- 
vices (SB 124) 

• Adds podiatry services (SB 124) 

• Increases personal needs 
allowance to $40 (HB 995) 


• Prohibits applicants and recipients 
from transferring assets to gain or 
maintain eligibility (SB 374) 

• Denies eligibility to recipients who 
dispose of their real property at less 
than (air market value (SB 376) 

• Adds children in foster care (HB 
714) 


• Requires payment ot vendor claims 
within 30 days of receipt (HB 1 LA) 

• Allows Inflation factor (5.2%) In 
allowable costs component for Mental 
Health Center reimbursement, effective 
7/1/84 (MA) 

• Increases upper limit for Mental Health 
Centers from 105% to 110% of median for 
each cost center (MA) 

• Reimburses ambulance providers at a 
base rate of $50, a mileage allowance ot 
$1 per mile, and itemized supplies at cost 
(MA) 

• Restricts out-of-state pharmacies Irom 
providing covered services when available 
within Kentucky (MA) 

• Sets allowable growth factor at $2.42 
per visit lor primary care services (MA) 

• Increases dispensing fee from $2,35 to 
3.25 (MA) 


• Requires annual report on the costs of 
dispensing prescription drugs (SB 191 LA) 

• Creates a technical advisory committee 
on consumer rlghls and client needs (HB 
154 LA) 

• Ends emergency ambulance service re- 
quirement to he a licensed conforming ser- 
vice (MA) 

• Imposes lien on property owned 
by certain recipients In SNFs or ICFs 
(SB 376) 

• Directs attorney general to con- 
duct fraud and abuse investigations 
(HB 847) 

• Mandates annual audit of 15% of 
personal care homos, family care 
homes, SNFs, ICFs and ICFs/MR to 
assure personal needs allowance is 
not abused by the facilities (HB 995) 

• Prohibits SNFs from Medicaid It 
such facilities: charge private pay 
patients higher rates, require an ad- 
mission fee greater than $100, or 
that the applicant Is not and will not 
attempt to become eligible for 
Medicaid. Also requires certain data 
submission and reduces payments 
for noncompliance (HB 956) 


• Terminates primary care nclwork In Jot 
ferson County (Cllicarc), offccllvo 7/1/84 
(GA) 

• Terminates implcnir n1.i hon of contrac 
ting with PPOs lor IP hospital services for 
recipients In Fayoltc County (GA) 

• Establishes family responsibility 
tor sharing the costs ot long-term 
caro (SB 373) 

• Requests the adoption of an open 
Medicaid drug formulary (HCR 82) 

• Directs a study on the administra- 
tion of the Social Security Disability 
programs (HCR 120) 


LOUISIANA 


• Adds dental services (SB 857 LA. Act 
259 of 1964) 

* Limits prescriptions to 4 per month 
unless verified as medically 
necessary (HB 1532) 




• Limits reimbursement to generic 
equivalent under certain cir- 
cumstances (HB 1434) 


• Denies state tax deductions or exemp- 
tions to hospitals denying services to 
Medicaid recipients (SB 80 LA) 

• Issues ID cards to recipients (HB 
1139} 


• Requests a review ol the standards for 
nursing homes participating In the Medicaid 
program (SCR 141 LA) 



14 July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


trrUnlo IU Imrltuvt 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


MAINE 








• Added nursomldwlln services In 1983 
(MA) 

" Provides developmental d;iy program 
services tn mentally retarded in ICI s/SNI s 
(MA) 


■ Adds children ot intact families -Hibicotf 
Hds (LI) 18-1? LA, Chap 8-19 ol 1984) 

• Continues covorago of persons 
rosidlng in cortoin boarding homes it 
federal covorago Is discontinued (LD 
2206) 


• Increases reimbursement lor certain 
OME Items (MA) 

• Increased celling on routine services lor 
boarding homes Irom S572 to $582 (MA) 

• Appropriates funds to increase 
reimbursement rates for ambulance 
services (LD 2396) 

• Bases reimbursement for medical 
equipment and supplies on a profile 
reflecting usual and customary 
charges (LD 2012) 


• Matches accounts in financial institu- 
tions with recipients or applicants (Chap 
784 of 1984) 

• Eliminates certain prior authorization re- 
quirements (MA) 

• Revises rules to allow prepaid capitation 
contracts with state-qualified HMOs (MA) 

• Repeals boarding home regula- 
tions (MP) 




MARYLAND 








• Established a llmll on lunation) hospital 
days based on DIIGs (MA) 

• Adds homo coverage ol supplies and 
cqulpmonl lor spinal enrd dyslunctlon and 
diabetic monitoring (MA) 

• Reimburses recipients enrolled In tbo 
Kidney Disease Program rccelvlnn home 
dialysis supplies and equipment (MA) 

• Covers lllc-savlng llvci transplants (MA) 

• Exempts speclnllzod transplant 
centers from 20-day (or DRG-basod) 
limit tor kidney and livor transplants 
(MP) 




• Reimburses for nurse anesthetist ser- 
vices (HB 566 LA; Chap 424 ol 1984) 

• Allows Health Services Cost Review 
Commission to consider the rales lor 
similar services in determining reimburse- 
ment lor clinic services (HB 1251 LA; Chap 
470 ol 1984) 

• Increases maximum payment lor physi- 
cian component ol an OP or clinic visit from 
$1.50 to S3. 00 (MA) 

• Allows vision care, hearing aid and 
EPSDT providers to retain discounts on a 
product (MA) 

• Prohibits providers Irom seeking pay- 
ment from the recipient when payment is 
denied due to late submission ol claim 
(MA) 

• Reimburses hospitals 70% ol charges or 
actual costs for life-saving liver transplants 
(MA) 

• Requires personal care providers 
bo given highest priority for timely 
reimbursement (HB 1039) 

• Limits reimbursement for acute 
and chronic care to inpatient ser- 
vices (HB 1086) 

• Sets rates for certain nonprofit 
facilities (HB 1228) 


• Requires local health department to im- 
mediately determine whether an alleged 
victim of child abuse is eligible lor Medicaid 
(HB 547 LA; Chap 631 ol 1984) 

• Requires a review of patient medical 
records to certify medically necessary 
days (MA) 

• Creates the State Health and 
Human Services Finance Commis- 
sion to administer the Medicaid and 
block grant programs (HB 1388) 

• Allows use of Medicaid funds for 
habituation services of MR/DD pro- 
gram (HB 1 100) 

• Earmarks certain Medicaid funds 
for Community Services Trust Fund 
(HB 1206) 

• Permits noncompeting source ser- 
vices procurement for the provision 
ot services (HB 1530) 


• Establishes a loan guarantee fund 
for long term care and requires par- 
ticipants to allocate 75% of beds to 
Medicaid recipients (HB 648) 

• Urges the development of a home- 
and community-based services 
waiver (2 1 76) for chronically mental- 
ly ill persons (SJR 30) 

• Requests the governor to appoint 
a Medicaid Health Cost Contain- 
ment Task Force (SJR 29) 



July 1984 15 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS Til IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


MASSACHUSETTS 






• Increases personal care 
allowance to $50 per month (SB 
807) 

• Requires continued hospitalization 
of recipients in a chronic disease or 
rehabilitation hospital unless 
available in a hospital within 25 
miles of patient's home (HB 4596) 

• Restores annual cost-of-living in- 
creases for the aged, blind and 
disabled (HB 1578) 

• Limits inpatient hospital to 40 days 
per year (HB 5017) 

• Prohibits coverage of drugs to 
treat colds (HB 5372) 


• Increases income exemption to 
150% of Medicaid minimum (HB 
323, HB 4590) 

• Adds children under the age of 21 
in private mental hospitals (HB 
2343) 

• Covers pregnant women other- 
wise eligible upon medical verifica- 
tion (SB 773) 

• Adds certain aged and disabled 
persons (HB 4583) 

• Creates Certificate of Medical In- 
digency program which prohibits 
Medicaid providers from refusing 
medical care to a certificate holder 
who is unable to make advance pay- 
ment for the medical care (SB 804) 

• Sets minimum income exemption 
from application towards medical 
payments at 133% of the AFDC pay- 
ment level (SSB 775) 

• Deletes $1 1 per month maximum 
exemption for costs of earning 
wages to be applied towards 
medical payments (SB 786) 

• Establishes one-month spend- 
down for severely disabled people, 
individuals in LTC, individuals who 
have difficulty becoming eligible for 
a 6-month spend-down, and in- 
dividuals at risk of institutionalization 
but capable of staying in the com- 
munity (HB 3854) 


• Modifies hospital payment system 
by fixing the amount of Medicaid dis- 
count in order to correct an uninten- 
tionally large discount (HB 6054) 

• Authorizes the establishment of 
rates for classes of providers which 
would be deemed adequate if the 
rates compensate 75% of providers 
for operating expenses, Investment 
and profit (HB 847) 

• Eliminates reimbursement for 
weekend admissions (HB 4586) 

• Requires that payments to chronic 
disease hospitals must meet the 
costs incurred by efficiently and 
economically operated facilities (HB 
1562) 

• Limits reimbursement for pre- 
operative admission to 2 days (HB 
4587) 

• Limits charges for patient visit In 
hospital to one per two days of 
hospitalization (HB 5014) 

• Limits outstate weekend admis- 
sions to certified medical emergen- 
cies (HB 5019) 

• Reimburses nurse practitioners as 
a separate provider category (HB 
1217, HB 2557) 


" Increases TPL efforts by clarifying 
the type of information health in- 
surers must provide to help Identify 
Medicaid recipients with health in- 
surance (HB 200, HB 5456) 

• Authorlzos Imposition of certain 
penalties and clarifies cir- 
cumstances tor provider termination 
in the Medicaid program (HB 201) 

• Requires petitioner of probate for 
wills of individuals 65 or older to cer- 
tify that the deceased was not a reci- 
pient of Medicaid (HB 207) 

• Prevents providers from refusing 
to serve recipients If recipients re- 
quest services (HB 4190) 

• Prevents any actions that would 
affect the continuing care of a reci- 
pient admitted to a chronic disease 
hospital (SB 635) 

• Requires second opinion affirming 
the need to perform elective surqerv 
(HB 5016) 

• Reduces period prohibiting 
transfer of assets at less than market 
value from preceding 2 years to 1 
year (HB 5262) 

• Allows 6 month delay in termina- 
tion of L TC provider due to a convic- 
tion In order to arrange for the 
relocation of recipients (HB 5896) 

• Transfers Medicaid funded 
transportation and health aid ser- 
vices for the elderly to the Home 
Care system (SB 613, HB 1072, SB 
629, SB 644) 

• Creates a central purchasing 
agency and regional distribution 
centers (HB 879) 

• Directs pharmacies to post a 
notice that they participate In 
Medicaid (HB 1400) 

• Creates Division of Community 
Long Term Care Services to develop 
a comprehensive, community-based 
system with local agencies (HB 
1764. SB 805) 


• Received 2 home- and communllybascd 
services waivers (2176) lo: provide case 
management, personal core, aduli dnv 
residential, respite core, trans porta Hon and 
adoptive services to Individuals requiring 
ICF/Mfl level ot core; and provides case 
mortOQomenl, homomokor, chore, social 
day care, and respite com to elderly and 
disabled individuals (MA) 

• Creates a commission to review 
Medicaid expenditures for institu- 
tional services and initiatives to pro- 
mote noninstltutional alternatives for 
the care of tho oldorly (HB 1227) 

• Requires relativos to participate In 
the cost ot nursing homo caro (HB 
1753) 

• Reimburses children up to ono half 
of the cost of care of their parents 
residing at home but oligiblo tor SNF 
care (HB 4589) 

• Studies reimbursing up to half tho 
cost ot providing care to eligible per- 
sins residing with children (HB 4564) 

• Authorizes respite care pilot pro- 
ject for aged adults (HB 1221) 

• Studies the feasibility of providing 
personal care services to recipients 
in a rest homo (SB 568) 

• Directs the implementation ot a 
pilot claims processing program to 
reduce the costs of bank Interest for 
small providers (SB 577) 

continued 



July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPHUvt 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


MASSACHUSETTS continuec 














• Establishes statewide screening 
program to encourage alternative 
long term care (HB 2144) 

• Requires nursing homes to have 
insurance tor providing repayment 
to the state (HB 4546) 

• Prohibits reductions in benefits 
due to benefit increases in Medicare 
(HB 31 10) 

• Prohibits transfer of patients 
becoming Medicaid recipients and 
establishes criteria for other 
transfers (HB 3484) 

• Requires licensee of health care to 
provide services to Medicaid reci- 
pients under the Medicare program 
(HB 4192) 

• Makes Medicaid fraud a felony 
(HB 4550) 

• Directs agency to comply with 
federal regulations relative to audits 
of nursing homes (HB 4588) 

• Directs the use of generic drugs 
when appropriate (HB 5015) 

• Requires recipient to provide cer- 
tain information upon receiving 
prescribed drugs (HB 5018) 

• Requires insurers to provide 
enrollment information of 
policyholders (HB 5037) 

• Directs insurance commissioner to 
advise Medicaid agency of benefits 
offered in insurance held by reci- 
pients (SB 565) 




MICHIGAN 


• Eliminates the pharmacy copoy tot reel 
plenls enrolled In the Wnync County Physl 
clan Primary Sponsor Plan (MA) 

• Prohibits funding of abortion ex- 
cept to savo the life of tho mother 
(HB 5520) 

• Adds services of nurse midwivos 
(effective 10/1/84) (MP) 

• Allows x-rays by chiropractors 
(MC) 




• The budget bill tor FY 85 allows in- 
creases of: 7Vi% for IP hospitals; 
5% for certain physician visits; 5% 
(or ambulance, dental, vision and 
other special services; and raises 
fee screen for certain OP hospital 
charges from 50th percentile to 67th 
(LP) 


• Clarifies definition of fraud (HB 
5102) 

• Establishes antifraud unit to in- 
vestigate recipient fraud (Senate 
substitute for HB 5328) 

• Requires contracting with 
hospitals on a competitive bid basis 
(HB 4821, introduced in 1983) 

• Expands second opinion program 
(effective 10/1/84) (MP) 


• Creates a special committee to study the 
need lor changes in the stale's Medicaid 
program (HR 327 LA) 

• Requests renewal of Primary Men- 
tal Health Clinic Sponsorship Pro- 
gram which provides outpatient care 
services under a freedom of choice 
(2175) waiver (MP) 1 

continued 



July 1984 17 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


MICHIGAN continued 






• Concomitant with the transition to 
a DRG hospital reimbursement 
system, the agency proposes to 
switch IP hospital-based physician 
reimbursement from cost-based to 
fee-for-service (effective 10/1/84) 
(MP) 

• Modifies substance abuse reim- 
bursement by allowing hospitals to 
provide acute care detoxification 
under the DRG system, but limiting 
subacute detoxification and 
rehabilitation services to subacute 
substance abuse services providers 
receiving a positive determination ot 
need (MP) 


• Expands the list of procedures that 
can be reimbursed on on OP basis 
only (effective 1 0/1/84) (MP) 

• Institutes precortHlcatlon of elec- 
tive hospital admissions (offoctive 
10/1/84) (MP) 


• Appllod tor homo- and community- 
based sorvicos walvor (2 1 76) to pro- 
vide case managomont, habitation 
aid and 5 othor sorvicos to 
dovolopmontalyy disablod In- 
dividuals requiring ICF/SNF lovol ot 
care (MP)' 

• Published "Containing Medicaid 
Costs" by tho Michigan Modicaid 
Task Force. The report lists sovoral 
rocommondathnis including: explor- 
ing compotitivo bidding for certain 
DRGs; tho provision of tomporary 
rellot for hospitals with a high 
percentage of Modicaid pattonts; 
studying alternatives to physician 
rolmbursemont including a DRG- 
based systom; granting authority to 
ban providers who are not cost- 
effective; and oncouragomont of 
case managomont ana capitated 
ambulatory systoms (MC) 


MINNESOTA 


• Increases personal need 
allowance from $35 to $40 lor SNF 
residents and $70 for ICF residents 
fSF 1653) 

• Increases personal need 
allowance to $50 (SF 7929, SF 
1531) 


• Adds pregnant women who would other- 
wise be eligible II the child had been born 
(HF 1966 LA, Chap 534 ot 1984) 

• Allows interstate agreements that 
would provide medical services to 
children who are adopted interstate 
(SF 1454) 


• Increases operating cost payment rate 
by S.24/resldenl per day tor certain nurs- 
ing homes; effective 7/1/B4— 6/30/85 (HF 
2098 LA: Chap 641 ot 1984) 

• Directs development ol new procedures 
that lake Into account the mix ol nursing 
home resident needs, geographic location, 
and other (actors, effective 7/1/85 (HF 
2098 LA, Chap 641 of 1984) 

• Directs conversion ol hospital reimburse- 
ment from rate per admission to DRG (to 
the extent possible) by July 1984 (HF 
1966 LA, Chap 534 of 1964) 

• Increases payment cap for HMOs 
from 85% to 90% ot average per 
capita fee for non-HMO recipients 
(HF 1977, SF 1819) 

• Limits IP hospital treatment tor 
alcoholism or drug abuse to one per 
year If hospital Is reimbursed on a 
per episode basis (HF 1966, SF 
1865) 


• Clarities law prohibiting discrimination 
against Medicaid recipients In or applying 
for admission to a nursing homo (HF 2090 
LA; Chap 641 of 1984) 

• Prohibits, until July 1, 1985, a person or 
organization Irorrt controlling the delivery ot 
walvercd services to more than 50 per- 
sons (HF 2098 LA; Chap 641 of 1984) 

• Clarifies period of Ineligibility due to 
transfer ol assets al less than lair market 
value (HF 1966 LA. Chap 534 ol 1984) 

• Requires counties having con- 
tracts with prepaid health plans to 
present all available options to reci- 
pients (HF 1977, SF 1819) 

• Removes age 65 limit for recovery 
from decendent's estate (HF 2035) 

• Extends statute ot limitations for 
fraud (SF 1785, HF 1809) 


• Studios the characteristics ol providers 
who have the potential tor ottering homo- 
and community-based services under a 
2176 waiver (HF 2098 LA, Chap G41 ol 
1984) 

• Studies the concentration ol ownership 
In the nursing homes and residential care 
services for the mentally retarded (HF 
2098 LA; Chap 641 of 1984) 

• Studies the need far home- and 
community-based waivers lor chronically 
III children who would continue to be 
hospitalized without such a waiver (HF 
2317 LA; Chap 654 ot 1904) 

• Guarantees 6 months ol eligibility II reci- 
pient chooses an HMO (HF 1966 LA, Chap 
534 of 1984) 

• Requires an assessment of the ap- 
propriateness and quality of care furnished 
to private paying residents In nursing 
homes and boarding care homes certified a 
Medicaid provider (HB 2098 LA, Chap 641 
of 1984) 

continued 



18 July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFrtLIINu 
BEIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


MINNESOTA continued 












• Exempts iCFs/MR with approved 
bed reduction or coversion plans 
from payment limits (SF 1641) 




• Received a second home- and 
community-based services waiver (2176) 
lo provide case management, respite care, 
homemaker and habitation services for 
the mentally retarded (MA) 

• Studies the need for a home- and 
community-based waiver (2176) tor 
disabled individuals under the aoe of 
65 (SF 1865) y 


MISSISSIPPI 








• Decreases limit on hospital days frOffl 20 
lo 15 per year (MA) 

• Eliminates piiymonl ol Pari A Medicare 
coinsurance 7/1/84 (MA) 

• Implements copoy on drugs otlectlvo 
March 1 and on all other allowable services 
effective 7/1/B4 (MA) 

• Limits coverage ol homo health medical 
supplies lo $50 per month unless prior 
authorization is received (MA) 

• Establishes copays on drugs and 
physician services (HB 566) 

• Establishes copays on all sorvlcos 
permitted by TEFRA (HB 919) 

• Adds homo- and community- 
based services (SB 2194)' 


• Delays landing ol ambulatory services 
tor children under age 18, and prenatal and 
delivery services lor pregnant women 
without children, tor another year, ending 
7/1/05 (SB 2B2G LA) 

• Sots monthly incomo eligibility limit 
at $863, or higher If set by the 
Modlcald Commission, for patients 
In corlaln medical facilities (HB 569) 


• Limits ellective date lor nursing home 
reimbursement to the date the authoriza- 
tion lorm Is signed by the physician (MA) 

• Limits coverage ol pathology services 
and reimbursement based on a lee 
schedule (MA) 

• Sets criteria for SNF/ICF reim- 
bursement for depreciation ex- 
penses when ownership is transfer- 
red (HB 971) 

• Authorizes Medicaid Commission 
to develop a method of SNF/ICF 
reimbursement tor depreciation 
when ownership Is transferred (HB 
972) 

• Requires nursing homes be a par- 
ticipant in Medicare as a condition 
for Medicaid payment (SB 2199, HB 
672) 

• Prohibits reimbursement to certain 
hospitals that have converted beds 
to skilled nursing beds (SB 2755) 


• Abolishes Medicaid Commission and 
translers duties to Division of Medicaid in 
the Office of the Governor effective 7/1/84 
(SB 3050 LA) 

• Creates a Medicaid Fraud Control Unit In 
Attorney General's office (SB 2671 LA) 

• Requires prior authorization for drugs us- 
ed to treat arthritis (MA) 

• Requires review ol hospital admissions 
on day of admission or day after, if a 
weekend admission (MA) 

• Requires prior authorization of panorex 
or full mouth x-ray (MA) 

• Changes membership of the 
Medicaid Commission (HB 842, HB 
996, SB 2003. SB 2822) 

• Transfers duties of the Medicaid 
Commission to the State Board of 
Health (HB 918) 

• Increases maximum Medicaid ap- 
propriation to $90 million (SB 2191) 

• Supplemental appropriation of $4 
million (SB 2192) 

• Deems any funds left by recipient 
dying intestate and without heirs 
while in a LTC facility shall be 
deposited with Medicaid program 
(SB 2213) 

• Prohibits damage awards for pain, 
suffering or impairment resulting 
from services provided by a 
Medicaid provider (SB 2670) 

• Prohibits providers filing for 
bankruptcy while owing debts to a 
government agency resulting from 
participation in Medicaid (SB 2756) 


• Extends CON moratorium on SNFs/ICFs 
(SB 2682 LA) 

• Provides income tax exemption for 
individuals having a physically or 
mentally disabled child living at 
home (SB 2198) 

• Urges Congress to remove restric- 
tions on imposing copays (SCR 536) 



July 1984 19 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


MISSOURI 








• Deleted selected drugs Irom the drug for- 
mulary and expanded the number ol drugs 
under MAC (MA) 

• Alters copays hy adding a S2 copay on 
prescriptions costing S25 or more and hy 
lowering the age exemption Irom aqe 21 to 
18 and under (MA) 

• Covers liver, heart, and heart-lung 
transplants on a prior authorization basis 
(MA) 

• Adds hospice services (HB 1129) 

• Decreases limit on eyeglass 
frames lor children Irom one pair per 
two years to one pair per year (MC) 






• Disallows adjustments to paid IP hospita 
charges unless late charges are Identifier, 
on the Medicare/Medicald cost report (MA; 

• Requires separate billing tor IP radiology 
and pathology services (MA) 

• Sets Interim payments tor OP department 
services at 60% ot charges, however, 
retroactive settlements will be based on 
the lesser ot 80% ol billed chargos or 
reasonable costs (MA) 

• Deletes reimbursement tor IP hospital 
physician visits delivered Friday or Satur- 
day tor admissions that occurred Friday or 
Saturday, except tor emergencies (MA) 

• Established a list ot surgical procedures 
to be reimbursed only it performed on an 
OP basis (MA) 

• Restores the reimbursement reductions 
Instituted In 12/83: IP hospital Irom 50 
percentile ol costs to 75 percentile; and OP 
hospital payments Irom 50%-60% ol 
costs to the lesser ol 80% ol reasonable 
costs or billed charges (MA) 

• To discourage use ol ER, the lees lor 
evening, Sunday and holiday office visits 
were Increased (MA) 

• Limits reimbursement of physician and 
podiatrist weekend IP hospital visits to 
emergencies where surgery follows within 
24 hours or delivery within 48 hours ol ad- 
mission (MA) 

• Requires separate billing (or hospital- 
based physicians (MA) 

• Requires claims be paid within 30 
days and interest be paid on late 
payments (SB 541) 

• Places a cap per unit on home 
health services (MP) 

• Reimburses IP hospital visits by 
podiatrists to PAS length ot stay 
limits (MP) 


• Performs post payment review ot 
hospital pacemaker surgery (MA) 

• Expands second opinion program (MA) 

• Implements a mandatory proadmlsslon 
screening program (or nursing homo corn 
(MA) 

• Requires prior authorization for binaural 
hearing olds (MA) 

• Reviews drug claims lor appropriateness 
of drug therapy with providers being In- 
formed ol contraindications (MA) 

• institutes review, by pharmacists, 
of drug regimens ot nursing home 
residents (MP) 

• Develops an automated prior 
authorization system (MP) 

• Institutes an audit to limit home 
health visits to 100 units ol services 
per year (MP) 


• Hccolvcd home- and Domtnunltv-baied 
services waiver (2176) to provide case 
management services lor severely III and 
disabled children (MA) 

• Implemented a Prepaid Hcalth/Physlclnn 
Sponsor Program In Jackson County lor 
AFDC recipients (MA) 

• Creates ■■Pro-compotltlon Health 
Caro permits, prolorrod provider ar- 
rangements and othor competitive 
policies (HB 1296) 

• Expands enrollment In prepaid 
care In St. Louis tor llscal year (MP) 


MONTANA 






• Adds coverage ot swing beds (MA) 

• Covers second opinions for surgery (MA) 











20 July 1984 



I POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


NEBRASKA 






• Conforms coverage of CT icani to 
Medicare policy (MA) 


• Adds Rlblcotf kids, under 21 (LE 
1127) 


• Allows agency 1o enter Into contracts on 
a bid or negotiated basis (LB 904 LA) 

• Implements a prospective reim- 
bursement system for long-term 
care facilities based on the needs of 
the patient (LB 798) 

• Advances phase-out of county 
contribution to Medicaid (LB 870) 

• Prohibits reimbursement to phar- 
macies that fail to return unused unit 
dose medications provided to nurs- 
ing homes (LB 90S) 


• increases TPL efforts by assigning reci 
plent rights of recovery to agency (LB 723 
LA) 


• Received home- and community-based 
services waiver (2176) to provide habilita- 
tion services to mentally retarded reci- 
pients (MA) 

• Authorizes a demonstration physi- 
cian case management program (LB 

• Establishes a demonstration pro- 
gram for selective contracting with 
hospitals (LB 780) 

• Establishes a certification pro- 
cedure for RN-midwives and nurse 
practitioners (LB 761. LB 724) 


NEVADA 






■ Exempts Individuals under 19 years of 
age from copays (effective 12/1/83) (MA) 

• Amend copays to conform to 
TEFRA (MP) 


• Extends eligibility to first- time pregnanl 
women when verified (effective 11/1/83] 
(MA) 

• Eliminated partial-month qualifying tor 
high-Income Institutional cases (effective 
12/1/83) (MA) 


• Requests, In biennial budget, a 
raise In payments to practitioners 
from medians of calendar year 1979 
to medians of calendar year 1984 
(LP) 






NEW HAMPSHIRE 




• Increased standard ol need for Old Age 
Assistance (OAA), Aid to Permanently and 
Totally Disabled (APTO), and aid to the 
Needy Blind, effective 1/1/84 (LA) 

• Increased Incomo limit tor nursing home 
residents from $767 to $794 (MA) 


• Adds nurse practitioner as a separate 
provider category (MA) 


• Requires prior authorization of all hearing 
aid services except evaluations (MA) 


• Received second home- and community- 
based services waiver (2176) to provide 
case management, respite care and other 
similar services to elderly and chronically 
ill individuals (MA) 


NEW JERSEY 


• Provides personal care assistant ser- 
vices to rcclpents in a boarding house or In 
their home (MA) 

• Prohibits copays unless mandated by 
tederal law (AB 820, AB 3569 LA, Chup 
56 of 1984) 

• Adds IP/OP drug abuse services (AB 
160, SB 331 LA) 

• Covers 10 bed reservation days 
(AB 985, SB 1044, SB 1100) 


• Increased Income Rliglhllllv st.mil.-iid tot 
nursing borne residents to $882/month 
MA) 

• Adds medically needy program 
(AB 608, SB 1718) 


• Ends reimbursement for 26 drugs the 
FDA has proposed to withdraw from the 
market (MA) 

• Clarifies county maintenance 
costs for Medicaid eligibles residing 
in state hospitals for the mentally ill 
(SB 1062) 

• Permits reimbursement ad- 
ustments for ICFs/SNFs experienc- 
ng financial hardship due to a high 
oercent of Medicaid patients (SB 
1513) 


• Matches wages and health 
benefits from employers with reci- 
pients (AB 283) 

• Permits hospitals to operate a long 
term care unit for recipients (SB 61) 

• Funds bed reservation days from 
the Casino Revenue Fund (SB 87, 
SB 295) 


• Establishes the Transitional Ser- 
vices Program to fund projects 
under home- and community-based 
waivers (2176) (AB 4091) 

♦ Creates the Nursing Home Financ- 
ing Authority (AB 153) 

continued 



July 1984 21 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


NEW JERSEY continued 






• Covers all lawfully prescribed 
drugs (AB 392) 

• Covers 14 bed reservation days 
(SB 1099) 

• Increases personal needs 
allowance (SB 1876) 


• Establishes Medicaid-only 
replacement program tor a small 
group of former SSI recipients (SB 
975) 

* Studies the feasibility of extending 
coverage to handicapped children 
(SB 760) 


• Requires provider, upon notifica- 
tion of an applicant's retroactive 
eligibility, to reimburse the applicant 
tor services paid by the applicant 
during the retroactive period, and to 
submit claims to the state agency 
(SB 1513) 


• Matches recipients with tax 
records and employee hoalth 
benefits, and requires a study on the 
law's effectiveness (AB 1282, SB 
1838) 

• Transmits doath certificate infor- 
mation to state agency (AB 54 1) 

• Prohibits hospitals and SNFs/ICFs 
from requiring donations or similar 
charges as a precondition of admis- 
sion and prohibits such facilities 
from requiring minimum timo period 
as a private pay (AB 1096. AB 872 
SB 1513) 

• Directs stato agency to rocovor 
cost of bonofits recetvod by reci- 
pients making improper transfer of 
assets (AB 872, SB 1513) 

• Prohibits SNFs/ICFs from denying 
admission to recipients it the facility 
has a Medicaid pationt occupancy 
rate b'llow the statewide average 
(AB 541, SB 1513) 

• Requires banks to report interest 
payments (or match with eligibility 
files (SB 1142) 




NEW MEXICO 




• Covers eye prostheses on a prior 
approval basis (MP) 




• Sets paymenl for drugs at the wholesale 
cost of the lesser expensive therapeutic 
equivalent drug and raises dispensing fee 
to $3.65 (HB 70 LA, CHAP 27 of 1984) 

• Reimburses SNFs and ICFs at the lower 
of billed charges or a prospective rate, ef- 
fective 7/1/84 (MA) 

• Reimburses physician services normally 
provided In an office at 60% of charge 
base when performed In an OP hospital set- 
ting (MA) 

• Appropriate $1 million to upgrade 
payments to providers (SB 82) 


• Implements use of UBB2 claims lorm 
(MA) 

• Prohibits reimbursement under the 
state-funded Indigent Hosplta 
Claims Act when individual is eligi- 
ble for Medicaid (SB 26) 

• Provides priority to state in 
recovery of payments (SB 50) 


• Requests completion of study to 
create a statewide indigent fund 
with federal match (HJM 2) 

• Recommends continuation of the 
Health Care Cost Containment Task 
Force (HJM 3) 

• Revises coordinated community 
in-home care pilot program, under a 
2176 waiver, by expanding service 
area, increasing eligibility income 
level, and increasing copay deduc- 
tion tor a spouse (MP) 



July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
S MANAGEMENT 


OTHER 
STRATEGIES 


NEW YORK 






•Adds prosthotlc appliances lor 
deal Individuals (AB 1318) 
•Adds personal omergoncy 
response syslom os pan of homo 
care sorvlcos (AB 3002, SB 2373) 

• Adds services lor translator lor 
deal roclplont In IP/OP hospital or 
clinic setting (A 4350, SB 3514) 

• Requires Integration ol a personal 
care homo atlondant program with 
Informal caroglvor In the delivery ol 
home cam (AB 9891) 

• Adds reader or Interprotar services 
lor deal In their homo (AB 10967) 

• Allows continuous 21 hour per- 
sonal care sorvlces bo provldod 
when tound to be cost etloctlvo (AB 
6523) 

• Extends surgical covorago to In- 
cludo procoduros that threaten nor- 
mal activity (SB 9771) 

• Covers second surgical opinions 
only whnn authorized or requlrod by 
tho state agoncy (SB 9771) 


• Eliminates reduction ol bonellts tc 
SSI recipients resulting from living 
with other persons (AB 8112) 

• Incroasos standards of need to 
the aged, blind, and disabled (AB 
1 1003) 

• Excludes votoran's Insurance 
bonellts from eligibility determination 
(SB 10171) 

• Excludes recant social security 
and SSI Increosos In determining 
eligibility (AB9ti) 

• Adds cortaln needy Individuals tor 
long term homo hoatth care pro- 
grams (SB 7530, AB8816) 

• Adds two counties to a category 
with o higher standard ot monthly 
nood(AB 11297) 


• Increases the hospital- specific cap o 
emergency room rates to $60 plus 80% o 
the difference In costs between $60 ant 
$75 (AB 6789-B LA) 

• Increases fotal funding for physician anc 
dental fees by 30%. allows fargetln| 
higher rales tor primary and dental can 
services, and Increases lees tor prenala 
and delivery services by 100% (AB 
6789 B LA) 

• Increases drug dispensing lee to 
$1.25 (AB 9259. SB 7873) 

• Limits payments for long term 
home health care where two or more 
recipients reside In the seme 
household (AB 10261. SB 7705) 

• Allows consideration ot real pro- 
perty costs (such as age. size, loca- 
tion, condition, and torm of owner- 
ship) In determining reasonable 
valuation tor payment to resident of 
health care facilities (SB 9710) 


• Allows interstate agreements 1 
share information on Individual' 
wages lor use In verifying ellglbilit 
(A 5928. SB 1306) 

• Authorizes interstate agreement 
lor resolving cases ot disputec 
residence (AB 9083. SB 7358) 

• Allows state agency to assume 
role of fiscal Intermediary (AB 9110 

• Establishes differential reimburse- 
ment rates and bonus payments tc 
encourage cost-effectiveness in the 
administration of programs by socia 
service districts (AB 9185. SB 77951 

• Requires individuals who have 
received Medicaid services while a 
college student to reimburse the 
county social services program (AB 
9971) 

• Requires comprehensive evalua- 
tion of applicant's medical, social, 
psychological end environmental 
needs (AB 10765) 

• Authorizes imposition of ad- 
ministrative tines lor provider fraud 
(AB 9621, AB 10819) 

• Allows lock-in of recipient for alter- 
ing or misusing ID card (AB 5262) 

• Requires comprehensive evalua- 
tion of a child's medical, social, and 
environmental needs (SB 8278) 

• Removes prior approval re- 
quirements for dental prosthetic ap- 
pliances (SB 9620) 


? • Authorizes Monroe County Medicap Pro 
; led and the stale to test the feasibility ol 
/ converting to a capitation system tor reci- 
pients In Monroe County (AB 10823A LA) 

• Extends authority to Sunset-Park 
Lutheran Medical Center and Syracuse 
Community Health Center to operate a 
prepaid Medicaid capitation pronram (AB 
11666 LA) 

• Authorizes up to 7 comprehensive health 
services plans or prepaid health plans el- 
fectlve 4/1/85 (AB 6789-6 LA) 

• Authorizes approval ol physician case 
management programs In up to 10 social 
services districts (AB 6789-B LA) 

• Applies for home- and community- 
based services waiver (2176) which 
would provide case management, 
respite and habilitation services to 
disabled children requiring hospital, 
SNF or ICF level of care (AB 1031)' 

• Authorizes use of Medicaid fun- 
ding for 3 demonstration projects 
providing support services to 
developmentally disabled at home 
(AB 8291) 

• Establishes a foster family care 
demonstration program at St. Fran- 
cis Hospital and requests home- and 
community-based services waiver 
(AB 9059, SB 7685)- 

• Applies for home- and community- 
based waiver (2176) to provide case 
management and respite services 
for disabled children requiring SNF 
level ot care (MODEL WAIVER) (AB 
9126)- 

• Mandates periodic studies to 
determine appropriate drug dispens- 
ing tee (AB 2959, AB 7873) 

• Creates the Excessive Risk Health 
Insurance Program to replace the 
catastrophic law (AB 10097) 

• Provides tax credit for care provid- 
ed to recipients in the home (A 
10129, S 8326) 

continued 



July 1984 23 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


trrunlo lUIMrHUVb 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


NEW YORK continued 
















• DlfQQts state health planning 
agency to study tho feasibility of a 
standard application form for health 
and social son/ice proqrams (AB 
10445} 

• Authorizes presumptive eligibility 
demonstration programs for im 
dividuals transferring from acuto 
hospitals (SB 9195, AB 11067) 

• Croatos foster family caro 
demonstration programs for (ho 
oldorly to oncourage families (o pro- 
vldo community plecomont that 
sorvos as an aHornativo to long form 
caro institutionalization (AB 11066 
AB 6837) 

• Permits stato to limit placemont of 
now patlonts In a residential health 
care facility without a hearing it (ho 
facility does not moot sttilo regula- 
tions (SB 9805) 

■ Exempts 200% of povorty lovol lor 
2 from payment for medical ox- 
ponsos when LTC Is provided out- 
side an Institution and 200% of 
povorty lovol for 1 when L TC is pro- 
vided in en Institution (AB 11611)' 

• Creates personal caro homo atten- 
dant program io Intograte (he Infor- 
mal caroglver with the dolivory ol 
homo caro services (SB 969 1 ) 

• Requests a home- and 
community -based services waiver 
(2176) (o provide case manago- 
menl, respite, habitation and adult 
day health services lo the elderly 
(AB 11547)' 

• Exempts Bronx health plan 
Medicaid prepaid capitation pro- 
gram from state HMO regulations for 
a limltod period (AB 11644) 

• Applied for a freedom of choice 
(2 1 75) waiver to restrict recipients to 
the most cost-effective Ambulelte 
and livery providers via competitive 
bidding contracts (MP) ' 



24 July 1984 



POLICIES AFFECTING 


POLICIES AFFECTING 

CI li it'll ITV 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


NORTH CAROLINA 








• Extends copays lo OP hospital services 
lot the categorically needy (MA) 

• Delates copays lor IP hospital ser- 
vices (MP) 

• Extends physician copay to the 
categorically noody (MP) 

• Lowers physician copny from $1 
to $.50 for all groups (MP) 




• Increases drug dispensing fee 
from $3,22 to $3,50 (HB 1545) 




• Ends moratorium on nursing home 
construction (HB 1585) 


NORTH DAKOTA 






No now InltlatlvGs 










OHIO 






• Increases OP reimbursement by 20% 
and office visits by $25 lo $50 for certain 
surgeries, In order lo encourage use of 
lower cost sellings (MA) 

• Adds ambulatory surgery centers as a 
separate provider category (MA) 

• Implements DRG payment system for 
hospitals beginning 10/1/84 (MA) 


• Signed contracts with five agencies to do 
pre-admission certification of hospital ad- 
missions (MA) 

• Institutes preadmission certification for 
most elective hospital admissions (MA) 

• Initiates volume purchasing of opthalmic 
materials (MA) 

• Provides $25,000 grants to existing 
HMOs to begin serving Medicaid recipients 
(MA) 

• Provides, lor start up costs. $500,000 
grants to new HMOs that will serve 
Medicaid recipients (MA) 


• Applied for a freedom of choice 
(2175) waiver to permit a com- 
petitive bidding approach for arrang- 
ing and financing specified home 
care services (MP) ' 

• The Governor's Commission on 
Ohio Health Care costs issued a final 
report July. 1984. The report con- 
tains 6 strategies and 23 recommen- 
dations (GC) 


OKLAHOMA 


• Requests the stnlo maintain lite policy ot 
three lice prescriptions lot olderly reel' 
plenls (HJR 1061 LA) 

• Directs the extension of IP hospital 
benefits to a level authorized by tho 
Hospital Utilization Review Commit- 
tee and the state PSRO (HJR 1047) 

• Eliminates lifetime limit ol $-10,000 
per Illness (HJR 1017) 

• Covers Community Mental Health 
Center Clinic Services (MP) 


• Directs on increase In income 
eligibility standards to equal national 
poverty standards (HJR 1047) 

• Extends time limit for applying 
trom 90 days attor date of admission 
to 180 days (HJR 1047) 

• Covers unborn child (MP) 


• Directs an increase in payment 
level for emergency medical treat- 
ment (HJR 1047) 

• Requires generic drug substitution 
for prescriptions, with a MAC ap- 
plied on available products (MP) 


• Authorizes a social worker to 
make eligibility determinations at 
certain hospitals (HJR 1047) 

• Conforms imposition of liens on 
propedy to TEFRA (HB 1495) 





July 1984 25 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


brrUHlo IU IMrnUVt 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRAEGIES 


OREGON 


• Buys into Medicare Part 8 coverage tor 
menial health clients retroactive to 1/1/84 
(MA) 

• Adds coverage for blood drawing 
equipment and certain drugs under 
medical transportation (MP) 




• Maximum payment lor medical transpor- 
tation is not to exceed 75 percentile of 
Medicare rate as ol 7/1/83, which will be 
inflated thereafter by legislatively approved 
amounts (MA) 

• Over-the-counter contraceptive drugs 
and devices reimbursed at lesser of billed 
or 150% of estimated acquisition cost 
(MA) 

• Authorized payment lor ambulatory 
surgical center services (MA) 

• Defines MAC as the estimated acquisi- 
tion cost of drugs (MA) 

• Requires provider bill third parties 
for certain DME, supplies, and ap- 
pliances prior to billing state agency 
(MP) 


• Granted branch managers responsibility 
for allocating lunds lor miscellaneous 
medical services Including DME and sup- 
plies (MA) 

• Deletes prior authorization requirement 
tor detoxification services beyond 3 days 
(MA) 

• Requires prior authorization lor all DME 
related to OP services (MA) 

• Miscellaneous medical services for 
AFDC, GA, and foster care recipients arc 
prior authorized by the state agency; 
Senior Services Agency will perform 
similar prior authorization tor OAA, Aid to 
the Disabled and Aid to the Blind recipients 
(MA) 

• Allocates lunds on a monthly basis to 
assure the provision of private duty nurs- 
ing, physical and occupational therapy, 
speech and hearing services, and DME 
(MA) 

• Specifies normal settings tor procedures 
and requires a review ol claims when a 
less expensive setting was appropriate 
(MA) 

• Clarifies drug dispensing limitations to 
not exceed a 100 day supply (MA) 

• Coverage ol hyperalimentation after the 
second week requires prior authorization 
(MA) 

• Decreases time allowed between 
receipt of prior authorization and the 
provision of services (MP) 


Formed a task lorcc to develop drug cost 
conlrols (MA) 

• Developing an on-site Held survey ol drug 
ncqulsltlon costs (MA) 

• Issuos a monthly nowslottor to Inform 
irovldors of cost-ellccllvo alternatives la 
costly prescriptions (MA) 

• Investigating fiscal Impact ol reimbursing 
drugs at less than the average wholesale 
price (MA) 

• Investigating cost culling measures for 
drugs Including: a variable dispensing fee; 
a restricted drug lormulary; a mi piogrnm; 
and expanding the prior authorization 
system (MA) 

Bccolvcd 2 freedom ol choice waivers 
(2175) to Implement a pilot cupllatcd 
physician case management program In 
selected areas (MA) 

• Requests continuation of homo- 
and community-based waiver (2176) 
which provides numerous servicos 
to the elderly, disabled, mentally 
retarded and developmental^ 
disabled (MP) ' 


PENNSYLVANIA 


• Covers vaccines for medically needy 
through the EPSDT program (MA) 

• Expands dental services lor medically 
needy under age 21 (MA) 

■ Expands coverage for diagnostic 
radiology, radiation therapy, nuclear 
medicine, and medical diagnostic pro- 
cedures (MA) 

• Implements copays on most services ef- 
fective 9/1/84 (MA) 

• Prohibits copays (SB 1407) 




• Implements prospective payment (DRG) 
system for hospitals effective 7/1/84 (MA) 

• Limits allowable interest on capital cost 
to prime rate lor nursing homes (MA) 

• Limits nursing home general administra- 
tion costs to no more than 12% ol 
operating costs including depreciation and 
interest (MA) 

• Raised prescription drug dispensing lee 
to $2.50 tor all pharmacies (MA| 


• Removes prior authorization requirement 
for drugs costing over $15.00 (MA) 

• Uses Red Book average wholesale price 
as a method to determine the estimated 
acquisition cost lor drugs (MA) 

• Requires prior authorization for certain 
dental procedures (MA) 

■ Adopted comprehensive Iraud and abuse 
regulations (MA) 


• Received a home- and community-based 
services waiver (2176) to provide case 
management, adult day care, h animation, 
and other services to mentally retarded 
persons In Allegheny Counly requiring a 
SNF/ICF level ol care (MA) 

• Develops a health insuring 
organization (HIO) demonstration 
project in Philadelphia to serve 
100,000 recipients (MP) 

continued 



July 1984 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


PENNSYLVANIA continued 




prohibits non-emergency surgery 
unless verHed h , wo lm l I 
surgeons (HB 2S19) 




• Limits number of dispensing fees to phar 
macles lor certain medicines dispensed t 
recipients In nursing facilities (MA) 

• Disapproves proposed ceilings to 
S/VFs and ICFs (HR 1B1) 

• Implements prudent purchas 
Ing/bldding concepts tor orthopedic 
shoes, eyeglasses and frames anc 
prescription drugs (MC) 

• increases surgical tees from 19% 
of usual charges to approximately 
41% effective January 1, 1985 (MC) 

• Increases physiclen fees tor 
medical end diagnostic procedures 
(MC) 


• Revised ihe administration of funds fo 
recipient transportation by distributing the 
funds and responsibility to the county 
governments or local contractors (MA) 

• Establishes physician lock-in pro- 
gram (MC) 

• Implements six pre-admission 
assessment projects for recipients 
applying for SNF/ICF care (MC) 


• Implements primary nealth care 
center demonstration project in 
Luzerne and Wyoming counties 
(MC) 


RHODE ISLAND 






• Adds covoiagc In ICF lor Iho mitlil .illy 
needy only (MA) 

• Ellmlnolcs 90 day limitation on SNF loi 
medically neody only (MA) 

• Increases personal noods 
allowance to $35 (HB 7138) 










SOUTH CAROLINA 




• Adds personal enro services, respite set 
vices and medical day care, effecllvo 
10/1/64 (MA) 

• Adopls open drop lorimdnry, otloctlve 
10/1/64 (MA) 

• Extends IP hospital limit Irom 12 to 26 
lor EPSDT recipients (MA) 


•Established a limited Medically Needy 
Program tor pregnant women aod Hlblcoft 
kids— children onder age 18 trom Intact 
lomlllos. ollccllvc 10/1/B4 (MA) 


• Reimburses oral surgeons tor services 
previously limited to physicians, effective 
10/1/84 (MA) 


• Responsibility tor Medicaid, Title XX 
SSBG and state health planning transferred 
(o the State Health and Human Services 
Finance Commission. All Medicaid policy 
will be channeled through the state health 
planning process (SB 132 LA) 

• Approves regulations governing 
civil rights compliance reviews of 
providers (HJR 3716) 


• Resolves that the Department of Social 
Services assure that Medicaid expen- 
ditures be kept at an amount that 
guarantees receipt ot a rebate tor federal 
funds withheld (HB 3361 LA) 

* Applied for a home- and 
community-based services waiver 
(2176) to provide personal care, 
home-delivered meals, respite care 
and therapy services to Medicaid 
recipients eligible for long-term care 
(MP)' 



July 1984 27 



POLICIES AFFECTING 
BENEFITS 


PHI iriF<t AFFFPTIMP 
i ULlL.lt o HrrtU 1 Iriu 

ELIGIBILITY 


Dill IPIEC ACEEPTIUP 
rULIl.lt;> ArrtLIINu 

REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STATEGIES 


SOUTH DAKOTA 




• Expands dental services lor recipients 
over the age of 20 (HB 1294 LA) 

• Adds S3 copay (or physicians visits and 
$3 copay tor each hospital admission (MA) 






• Prohibits recipients from transferring 
assets at loss than fair market value (SB 
35 LA) 

* Exempted certain county trom con- 
tributing moro than $20,800 to medical 
fund (HB 1251 LA) Vetoed by Govcnor 




TENNESSEE 




• Limits IP hospital days and hospital 
physician visits to 20 per year lor reci- 
pients under age 21, and to 14 (or reci- 
pients age 21 and over (MA) 

• Covers PUVA therapy lor psoriasis under 
certain conditions (MA) 

• Limits denial program to one exam per 6 
months (MA) 

• Removes certain diagnoses for justifying 
a hysterectomy (MA) 

• Approves DMSO lor treatment of car- 
cinoma of the bladder (MA) 

• Adds laser beam treatment for der- 
matological lesions and extended wear 
contact lenses to the Noncovered Services 
List (MA) 


• Revises standard of need for AFDC by 
deducting value ol housing assistance, 
food stamps and Medicaid (HB 1605 LA, 
Chapter 918 PL of 1984) 


• Requires providers to split bill services 
which span the eHectlve date of a tato 
change (MA) 

• Utilizes prior years' data for IP routine 
service cost limitation II Medicare data 
unavailable (MA) 

• Establishes criteria for reimbursing am- 
bulatory surgical procedures that are per- 
formed in an IP setting (MA) 


• Allows special administrative hearings 
for appeals to denial of claims under $500 
(SB 1962, HB 1844 LA) 

• Eliminates prior authorliatlon require- 
ment fur Septoplasty procedures (MA) 

• Entered Into a contractual agreement 
with the Tennessee Primary Care Network 
to Implement an HIO (MA) 

• Uses the UB-82 claim form (MP) 


• Received a homo and communlly-based 
scrvlcos wolver (2176) to provide case 
management, respite core, personal core, 
and other similar sorvlcos to Individuals In 
Shelby County requiring ICF/SNF level ol 
care (MA) 

• Requires providers of medical ser- 
vices, equipment, supplies or drugs 
to provido an itemized list of services 
(SB 2022, HB 1983) 


TEXAS 




• Adds SNF and home health ser- 
vices (or eligibles under age 21 (MP) 


• Provides Medicaid coverage to 
former AFDC recipients who obtain 
employment but are still in need of- 
continued medical assistance (HB 
79XX) 




• Mandates Medicare Title XVIII par- 
ticipation for SNFs as a condition tor 
Title XIX participation (MP) 


• Applied tor 2 home- and 
community-based services waivers 
(2176) to: provide case manage- 
ment, respite care, nursing, habitua- 
tion, and other services to certain in- 
dividuals requiring an ICF/MR level 
of care; and provide Medicaid ser- 
vices, home health, personal care, 
and nursing care to categorically 
needy, blind or disabled Individuals 
under 21 who require a SNF/ICF or 
ICF/MR level of care (MODEL 
WAIVER) (MP)' 



28 July 198-1 



POLICIES AFFECTING 
BENEFITS 


POLICIES AFFECTING 
ELIGIBILITY 


POLICIES AFFECTING 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


UTAH 












• Establishes competitive bidding 
for home health services (MP) 


• Establishes departmental administrative 
hearing examiner to review recipient ap- 
peals and allows appeals of decisions in 
district court (HB 16 LA) 

• Strengthens state's right to TPL 
recoveries lor services provided to reci- 
pients (HB 13 LA) 

• Allows department to determine through 
an administrative process whether an in- 
dividual has received assistance over- 
payments (HB 18 LA) 

• Provides that when a person to whom 
support Is owed receives public 
assistance, the right to that support passes 
lo the state by operation of law (SB 4 LA) 

• Expands physician and pharmacy lock-in 
program Irom 150 to 300 recipients (MA) 

• Creates a new category ol long-term 
care service for individuals requiring nurs- 
ing rehabilitation, called Intensive Skilled 
(MA) 


• Received renewal for case management 
and central broker waiver (2175-Freedom 
of Choice) to expand into rural areas (MA) 

• Allows manditory withholdings of child 
support payments (HB 15 LA) 

• Received a freedom of choice waiver 
(2175) to develop through a bidding pro- 
cess, a prepaid health plan to provide com- 
prehensive OP and residential services 
statewide to certain recipients who are 
mentally ill, developmental^ disabled, 
mentally retarded, chronic substance 
users, or are functionally impaired (MA) 

• Studies possible changes in the ORG 
system under Utah's Medicaid program, in- 
cluding the use of competitive bidding (HJR 
5XX LA) 

• Requires divorce decrees to 
assign responsibility for payment of 
reasonable and necessary medical 
and dental expenses of dependent 

Liiiiurtjii (no It) 


VERMONT 








• Increases li.islc need and shelter stan- 
dards to reflect cost d1 living Increases 
Irom 4/82-12/83 (MA) 


• Extends chiropractic coverage lo permit 
diagnosis without an x-ray (MA) 


• Reguires prior authorization tor more 
than 10 visits to chiropractic services (MA) 




VIRGINIA 


• Adds oyeglassos, dental work, 
hearing aid's and prosthosos for 
therapeutic use (HB 875) 


• Adds pregnant women who would other 
wise be cllqlblc II the child had been born' 
SB 200 LA) 

• Exempts prepaid funeral plans 
from resource consideration, up to a 
value of $1,500 (HB 411, HB 426, 
HB 491, HB 875) 

• Exempts non-income producing 
proporty from eligibility determina- 
tion (HB 473) 

• Adds children placed in foster 
homes or private institutions (HB 
387) 


■ Mandates repayment of reimbursement 
depreciation on sale or transfer of nursing 
home (SB 383 LA) 

• Pays the costs of unit dose drugs 
plus dispensing fee (HB 847) 

• Reguires cost-based reimburse- 
ment for local government-owned 
nursing homes (HB 911) 

• Exempts local government-owned 
nursing facilities from reimburse- 
ment ceilings (SB 135) 

• Requires higher reimbursement 
rates for SNFs in areas contiguous 
to Northern Virginia (HB 551) 

• Requests a study of basing reim- 
bursement on the amount of care a 
patient receives (HJR 158) 


• Establishes a lien on claims for funds due 
under uninsured motorists coverage (HB 
326 LA) 

• Creates Department of Medical 
Assistance Services to administer the 
Medicaid Program (SB 383 LA) 

• Permits Commissioner of Health to bring 
charges against recipients for fraud (HB 
663 LA) 

• Implements automated crossover 
system for Medicare IP/OP hospital claims 
tor recipients (MA) 

• Adopts use of ICD-9 CM procedures 
coding for hospital IP/ OP invoices (MA) 

• Requires annual report to include 
assessment of adequacy of 
Medicaid to indigent and the impact 
of raising levels of assistance (SB 
436} 


• Continues Joint Committee lo Monitor 
Long-Term Care for the study of: the policy 
ot releasing geriatric, mental, and mentally 
retarded patients into the community; alter- 
native nursing home reimbursement plant 
based on medical care required; and the 
cost effectiveness ot maintaining the aged 
in community settings (HJR 52 LA) 

• Provides that spouses are jointly 
and severally liable for necessary 
medical care furnished Neither (SB 
43) 

• Provides income tax credit for care 
of elderly persons (HB 657) 

6 Studies the feasibility of 
establishing a consolidated health 
care data base (HJR 27) 



July 1964 29 



PHI IPIF<\ AFFFPTINR 
r ULILICo Hrrtli 1 Irlu 

BENEFITS 


pfti trice AcccPTiur 
ELIGIBILITY 


nni IPICC ACCCPTiUP 

rULILIbo ArrbUIINu 
REIMBURSEMENT 


EFFORTS TO IMPROVE 
ADMINISTRATION 
& MANAGEMENT 


OTHER 
STRATEGIES 


WASHINGTON 










• Requires preadmission screening 
prior to admission to a nursing homo 
(HB 1518) 


• Conducts at least 7 one year demonslia 
tlon projects to test the cost-cltcctlvcncss 
ol providing uv and out-ol home respite 
cure services (HB 1137 LA) 

• Creatos a Joint Committee on 
Health Caro Reform to dovolop a 
plan for purchasing recipient ser- 
vices from managed health caro pro- 
grams (HB 1538) 


WEST VIRGINIA 


• Allows additional home health services 
beyond those mentioned in the law (SB 
675 LA) 










WISCONSIN 


• Exempts copays on primary provider of- 
fice visits exceeding 6 per year (AB 1009 
LA) 

• Exempts copays on authorized transpor- 
tation by a common carrier or private auto 
(AB 1009 LA) 

• Restores personal needs allow- 
ance from $40 to $45 per month (AB 
1078) 

• Will introduce legislation in 1985 
which restores coverage of drugs for 
medically needy and restores 
specific dental services (LC) 


• Exempts, during eligibility determination, 
autos owned by persons 65 or older, or 
who are blind or totally disabled (SB 673 
LA) 




• Requires random payroll Inspection of 
nursing homos named In complaints ol In- 
adequate slatting (SB 3XX LA) 

• Defines stale sharo far Inpatient 
psychiatric care and drug abuse treatment 
lor persons 22-64 years old within the first 
month (SB 673 LA) 

• Allows special consideration for 
HMOs having at least 50% of IP 
hospital days in teaching hospitals 
(AB 836) 

• Establishes a pilot project to verily 
eligibility by Income and asset check 
with department of revenue (AB 863, 


• Applied for home- and community- 
based services waiver (2 1 76) to pro- 
vide case management, homo 
health aid services, personal caro 
services, respite care, adult day 
health, habituation and other ser- 
vices for Individuals requiring 
SNF/ICF level of care (MP) ' 


WYOMING 


• Adds services in mental health institu- 
tions (SB 93 LA) 











APPENDIX 
STATE INDIGENT HEALTH CARE 
LEGISLATION AND STUDY COMMISSIONS OF 1984 



INTRODUCTION 

In 1984 there was an increase in the number of states addressing the 
health care needs of the medically indigent. Although the term "medically 
indigent" is difficult to define, it usually refers to those low-income in- 
dividuals who are uninsured and not eligible for a federally-supported pro- 
gram, such as Medicaid. It is important to note even insured individuals 
may become medically indigent due to high medical care expenses and in- 
adequate health insurance coverage. 

The term 'state indigent care programs' refers to those state- or county- 
funded programs that directly provide, or reimburse providers, for in- 
dividuals unable to afford needed medical care. Quite often such a program 
is the medical care component of a state's general assistance program for 



low-income people. 

The appendix lists legislative or executive brunch activities in the follow- 
ing manner: 

LAWS: lists important changes In the states indigent care program. 

STUDIES: lists those states that have published reports on issues affecting 
indigent care within the state or arc studying the issue under a tusk force or 
some type of commission. 

BILLS: lists important legislation that was considered during the 1984 
legislative session, or is being considered in those states still in session. 

Finally, major bills that could have a significant impact on health care for 
the indigent, such as catastrophic health care or risk pools, were included. 



ALABAMA 

STUDIES 

• The Lcgislalivc Joini Continuing Committee lo Sludy the Tax Structure 
of the Stale of A 1 . 1 1 ..iin. * and their staff arc examining the issue of indigent 
care. A report with legislative proposals is due prior lo the 1985 lcgislalivc 
session. 

BILLS 

SB 491, HB 760 Levies a hospital bed tax of $12.50 per day lo be deposited 
in the Hospital Indigent Care f und and creates the Hospital Indigent Care 
Lund Commission to allocate the fund. 

SJR 87X Creates a joint interim committee to sludy the financing of in- 
digent hospital care. 



ARIZONA 

BILLS 

AB 1081 Establishes a comprehensive Health Insurance Association lo 
provide health insurance lor persons unable lo obtain coverage, and re- 
quires a $200 deductible with a $1000 cap on out-of-pocket expenses ($2000 
for a family). 

HB 2253 Clarifies rules guiding recovery of costs resulting from private 
hospitals Healing the indigent. 



ARKANSAS 

STUDY GROUPS 

• The governor has appointed a task force lo study the needs of the 
medically indigent and to develop recommendations. The expected comple- 
tion date is December of I984. 



CALIFORNIA 
BILLS 

AB 578 Amends statute delineating indigent care responsibilities by: mak- 
ing the state instead of certain small counties at risk for expenditures 
beyond the appropriated amount and permitting the state to provide 
technical assistance to certain small counties that elect to independently ad- 
minister their indigent care program. 

AB 3887 Defines "medically necessary" as a reasonable and necessary ser- 
vice for the maintenance, improvement, or protection of health or the 
lessening of illness, disability, or pain. 

AB 2587 Establishes the following order of preference for counties selec- 
ting the method in which they will provide in-home supportive services: the 
county directly hire such personnel; the county contract with an agency; and 
finally, the county arrange for direct payment. 

AB 3380 Requests counties utilize existing nonprofit primary care 
resources prior to developing new county-operated resources when such 
resources are of equal quality and expense. 

SB 1 525 Requires the county to pay for the reasonable value of health care 
services when the county fails to furnish reasonably accessible emergency 
care or has otherwise failed to meet its statutory obligations to furnish 
health care. 

SB 2017 Extends (to 6/30/87) the provision that persons meeting income 
and resource requirements be eligible for county health services, and re- 
quires counties to submit their standards of aid and care to the state, which 
will distribute them to other counties. Disputes, when submitted by a coun- 
ty, over the responsibility for an indigent shall be decided by the state. 
ACR 118 Requests the University of California to plan and conduct a major 
study of indigent health care needs. 

AB 3779 Enacts the American Indian Clinic Facility Improvement Act of 
1 984 which would make loans and/or grants to certain clinics for providing 
the purchase of land, buildings, and other improvements. 
AB 166 Creates the California Health Insurance Association of which all 
carriers and self-insurers doing business in the state must be members or pay 
a fee. Residents who have been rejected by a carrier for benefits and 
coverages substantially similar to the association plan coverage are eligible. 

Rates shall not be excessive, inadequate or unfairly discriminatory, but in 
no event shall rates be more than 200% of the average rates for comparable 
coverage. A deductible of $500 and a coinsurnace of 20% are imposed. The 
maximum out-of-pocket payments shall not exceed $1,500 per individual or 
$3,000 per family. 



1 



COLORADO 

STUDIES 

• The Colorado Task Force on the Medically Indigent issued a 3-volume 
report titled, Colorado's Sick and Uninsured: We Can do Belter, January, 
1984. 
BILLS 

HB 1341 Requires provider of medical services to the medically indigent to 
make a good faith effort to obtain reimbursement from all other potential 
sources prior to receiving reimbursement from the state. 
HB 1397 Creates the Colorado Health Care Accountability and Manage- 
ment Plan (CHAMP). The Plan would develop and administer a prepaid, 
capitated health care system for individuals for whom group health in- 
surance is not available. CHAMP would be administered by a private con- 
tractor selected on the basis of competitive bids. 

SB 136 Transfers administration of the program for the medically indigent 
from the University of Colorado Hospital to the Department of Social Ser- 
vices. 

HB 1380 Creates a system of state health care certificates issued to eligible 
persons for the purchase of health insurance from qualified health services 
providers. Eligibility for the program would be det.-rmined by the counties 
and would extend to both the categorically needy under Medicaid and those 
who are medically indigent. Payments under the system would be on the 
basis of prepaid capitated contracts to be awarded by counties as a result of 
competitive bids. Individuals would be free to select providers of basic 
health services not under contract with the county. However, they would be 
liable for any additional charges in excess of what is allowed under the basic 
plan. The basic health services covered by the program are the same services 
required for participation in the Medicaid program. 

Implementation of the system is conditional upon receipt of federal 
waivers necessary to provide a new reimbursement, system for the basic 
health services. 

The bill would limit the number of recipients receiving care on a prepaid 
capitated basis in relation to the total of eligible recipients to: 20 percent by 
July 1, 1985; 40 percent by July 1, 1986; and 60 percent by July 1, 1987. 



FLORIDA 

LAWS 

HB 1324, Chapter 84-373, Laws of 1984 Permits (for up to two years) 
Hillsborough County to levy, by ordinance, a discretionary additional sales 
tax to provide health care to indigent patients. 



STUDIES 

SB 176 and 697, Chapter 84-35, Laws ol 1984 Directs the Department of 
Health and Rehabilitative Services to determine the feasibility of vising (he 
newly created Public Medical Assistance Trust Fund to reimburse hospitals 
for inpatient and outpatient services provided to the medically indigent 
(uninsureds with income below 1 50*Vo of the federal poverty level). The 
study is to be submitted to the legislature prior to February 1, 1985. 

BILLS 

HB 331 Proposes that a form be utilized by the regional referral hospitals 
for establishing the county of residence of an indigent receiving treatment. 

GEORGIA 

LAWS 

HB 1296, Acl 1300, Laws ol 1984 Revises the state law governing care for the 
indigent. First, it directs the state lo adopt slate-wide standards to deter- 
mine indigency and requires the governing authority of each county to 
designate a "health care advisory officer" to make determinations of in- 
digency for county residents. When a patient claims indigency the hospital 
notifies the officer and if the patient is determined eligible, the county of 
residence of the patient is liable for the payment. The law also prohibits 
hospitals performing emergency services from denying care lo any pregnant 
woman who presents herself in active labor. 
STUDIES 

HR 708 Creates the Joint Hospital Care for the Indigent Study Committee 
to study care for the medically indigent and the sale of public hospitals to 
private concerns. A report of their findings and recommendations is due 
December 1, 1984. 



IDAHO 

LAWS 

HB 641 Establishes the maximum reimbursement rate for indigent patients 
in long-term facilities as the unadjusted Medicaid rate or the unadjusted 
Medicare rate, whichever is greater. 
BILLS 

HB 728 Eliminates the exemption from state limitations that the ad 
valorem tax for the financing of the county medically indigent currently en- 
joys. 

HB 478 Provides that funding for the medii : l care of the medically in- 
digent is a county option and not a state mandate. 



2 



ILLINOIS 

BILLS 

HB 2350 Prohibits the state from establishing rales of payment to medical 
providers under the General Assistance and Local Aid to Medically Indigent 
Programs which differ from Medicaid payment rates. Also, ends the $500 
per admission limitation for inpatient hospital admissions. 
SB 1B66 Removes stale supervision of the local aid to the medically in- 
digent program (for individuals not eligible for Medicaid or General 
Assistance). 

INDIANA 

BILLS 

HB 308 Repeals statute governing hospital care for the indigent. 
SB 191 Allows counties and townships to appeal for an excess property tax 
levy ('/;% of assessed valuation) to pay costs incurred for hospital care of 
indigents if it is less expensive than issuing bonds. 

SB 439 ReplacC8 existing township poor relief program with a local 
assistance program. The bill would allow the township board of supervisors 
and hospitals to bring actions in circuit or superior courts for recovering the 
costs of care provided to tin individual able to pay. The slate, in place of 
townships, would establish eligibility criteria with a mandated minimum 
level of 110% of the federal poverty level. 

KENTUCKY 
STUDIES 

• As mandated by SCR 6, the Legislative Research Commission shall study 
the financing of health care for the indigent including: the number and 
place of resilience of persons who are uninsured or undcrinsured; eligibility 
restrictions under Medicaid; and the amount of uncompensated care pro- 
vided by hospitals, physicians, and other providers. The Commission on 
Financing Health Care for the Medically Indigent, which will oversee the 
study, must present a report to the Legislative Interim Joint Committee on 
Health and Welfare by August I, 1985. The next legislative session lor Ken- 
tucky begins January 1986. 
BILLS 

HB 859 Imposes a legal obligation on hospitals to provide medically 
necessary hospital care to its fair share of medically indigent patients. A 
hospital's fare share would be equal to the statewide arithmetic mean 
percentage of gross patient revenues used by hospitals to provide medically 
necessary hospital care to the medically indigent. This fair share is in addi- 
tion to any constractu.nl obligation (e.g. Hill-Burton) to supply indigent 



care, and hospitals failing to meet their share would be subject to a fine 
equal to one-and-one-half times the difference between the hospital's fair 
share and the amount of medically necessary hospital care for indigents the 
hospital does provide. Money collected from such fines would be used to 
subsidize medically indigent care provided by hospitals contributing more 
than their fair share. 

HB 528 Creates a state health insurance pool for residents without any 
third-party coverage. Initial rates must be between 1 50% and 200% of rates 
established as applicable for individual standard risks. 

MASSACHUSETTS 
BILLS 

SB 788. HB 3855 Amends General Relief statute by adding coverage of 
physician office visits, basic dental care, lab services, durable goods, eye 
care, home health care, and inpatient, outpatient and chronic care in 
municipal, county, and private nonprofit hospitals. 
HB 2140 Adds coverage of physician office visits, basic dental care, 
durable goods, eye care and home health care. Also directs the establish- 
ment of a capitation program to provide inpatient hospital care to recipients 
of General Relief in hospital facilities under contract with the state. 
HB 3667, HB 1233 Adds inpatient and outpatient hospital care, physician 
office visits, basic dental care, lab services, durable goods, eye care, and 
home health care as covered services. 

HB 3666 Permits hospitals, under the state prospective payment system, to 
write off the treatment of unemployed residents who lack third party 
coverage, or residents whose employer does not offer health insurance 
coverage and who cannot afford the costs of the services, as free care or bad 
debt. 

HB 3858 Creates a new program which issues a Certificate of Medical In- 
digency to individuals or families that meet Medicaid asset and resource re- 
quirements and whose income is not greater than three times the Medicaid 
standard. Eligibility would be reviewed every six months. 

No Medicaid provider shall refuse to provide medical care to a holder of a 
certificate due to inability to make an advance payment. The bill also pro- 
hibits Medicaid providers from refusing to negotiate a payment plan with a 
certificate holder. Acute care hospitals that receive reimbursement for free 
care or bad debt cannot refuse to provide care to a certificate holder. 
Repeated violations of this program could result in denial of determination 
of need or license revocation. 

SB 1729 Adds a space to the state income tax forms for taxpayers to check 
off if they wish to contribute one dollar to a fund to be used to pay for the 
expenses incurred by uninsured individuals. 



3 



MINNESOTA 

BILLS 

SF 1820 Adds hearing aids, prosthetic devices, lab and x-ray services to list 
of services covered under the General Assistance Medical Care program. 
SF 1787 Adds equipment necessary to administer insulin and diagnostic 
supplies and equipment for diabetics to monitor blood sugar levels to the 
list of covered services under the General Assistance Medical Care program. 



LOUISIANA 

BILLS 

HB 1195 Requires a minimum fee of $3.00 for outpatient service and $5.00 
for inpatient services provided at the Charity Hospital of New Orleans. 
HB 431 Prohibits hospitals or other medical facilities operated by the state 
from denying admission to indigents because available bed space is being 
utilized by patients able to pay for such hospitalization. 



MAINE 

BILLS 

LD 2170 Provides certain services (i.e., hospital outpatient services, physi- 
cian services, drugs, and limited nursing home care, but no inpatient 
hospital care) to those whose income and resources are insufficient to meet 
the cost of those services. Applicants shall be eligible for assistance if their 
residual liability (i.e., after all health insurance of other third-party payer 
benefits are applied to the cost of the care) exceeds the following amounts: 
a) for families with children, when medical expenses during a month are 
greater than the amount by which their net income exceeds the AFDC stan- 
dard of need level for a family of the same size; and b) for single people and 
couples without children, when medical expenses during a month are 
greater than the amount by which their net income exceeds the maximum 
countable income level for the state Supplemental Security Income Pro- 
gram. The bill also authorizes the state to establish an assigned risk pool to 
cover those who were refused coverage by at least three carriers or private 
health insurance companies. Finally, the bill would create a Special Select 
Commission on Access to Health Care for investigating the extent to which 
citizens in the state are without access to adequate health care. 



MARYLAND 

BILLS 

HB 567 Creates ;i st .it c -funded assistance program for financially distressed 
medical care facilities. Facilities must be located in Q medically underserved 
area or must primarily serve a health manpower shortage area, To receive 
assistance, facilities must meet a number of conditions including the 
establishment of a sliding fee schedule lor indigent patients and identify ad- 
ministrative procedures lor collecting payments from third-party payers. 



MISSISSIPPI 
LAWS 

HB 1064. Chapter 809, Laws ol 1984 Authorizes the Board of Supervisors of 
Holmes County to make an annual payment of $325,000 to the Indigent 
Care and Health, Education and Welfare Fund. This fund shall make 
payments to the Methodist Health systems. Inc. (which would agree to lease 
the Holmes County Hospital) for the treatment of the county indigent. This 
payment shall constitute the only payment which the county is authorized to 
make to the Methodist Health System. An indigent is defined as a Holmes 
county resident or family with an income which is not more than the current 
poverty guideline of the Community Services Administration. 
BILLS 

SB 2226 Establishes the Stale Comprehensive Health Association of which 
all insurers doing business in the state must become a member. A single in- 
surer, selected through a competitive bidding process, shall administer the 
plan. 

Persons eligible for the plan are individuals whose insurance coverage is 
involuntarily terminated for any reason other than nonpayment of 
premium. If such coverage is applied for within 60 days after the involun- 
tary termination, the effective date of the coverage shall be the date of the 
termination. 

The initial premium shall be equal to 150% of the average standard risk 
rates, with a ceiling set at 200%. The plan shall provide a choice of annual 
deductibles for major medical expenses coverage of $1,000, $1,500 or 
$2,000. If the covered costs incurred by the eligible person exceed the deduc- 
tible, the plan shall pay at least 80% of the additional costs. 
HB 179 Establishes an assigned risk plan for health insurance with over- 
sight provided by the health commissioner. The commissioner is to pro- 
mulgate regulations for (he program and may fix rates or minimum 
premiums. 



4 



NEBRASKA 
LAWS 

LB 886 Amends the State's General Assistance Statute lo transfer the adm- 
nislralivc responsibility for medical assistance programs for the poor from 
the state to the counties. The counties have the authority lo obtain reim- 
bursement for medical assistance or health services from the spouse, parent, 
or child of any recipient if they arc of sufficient financial ability. Applicants 
seeking county health services must give a right of subrogation to the county 
for claims against other third-parly payers involving reimbursement for 
medical care. 
BILLS 

LB 907 Creates a Catastrophic Health Insurance Pool lo provide protec- 
tion for (hose who have been rejected for health insurance coverage or 
whose insurance policy includes a restrictive rider limiting coverage due to a 
preexisting medical condition or whose health insurance coverage has been 
involuntarily terminated. Rates arc limited lo 150% of rates applicable to 
individual standard risks. 



NEW JERSEY 
BILLS 

AB 4064 Requires general hospitals to accept a patient and lo provide 
emergency medical services without regard to the patient's ability to pay, 
when a physician determines the services are necessary to prevent a life- 
threatening condition, or to prevent a serious deterioration of the in- 
dividual's medical condition. 

SB 1370, AB 1409 Continues residents' eligibility for the Pharmaceutical 
Assistance to lite Aged and Disabled (P.A.A.D.) notwithstanding the fact 
that their incomes may exceed income limits because of cost-of-living in- 
creases in Social Security benefits. 

SB 1409 Raises the P.A.A.D. income eligibility limits from $12,000 lo 
$14000 for single residents, and from $15,000 to $17,000 for married 
residents. 

AB 1290 Excludes from P.A.A.D. income determination, benefits from 
certain state-funded programs, proceeds form a spouse's life insurance, or 
damages received from personal injury. 



AB 664 Permits Ihe state to annually distribute forms lo P.A.A.D. reci- 
pients for updaling findings as lo the health needs of the recipients. The fin- 
dings of Ihe P.A.A.D. recipients' health needs are to be included in the 
commissioner's annual report lo the Governor and Ihe Legislature. 
AB 3844 Establishes a Cataslrophic Illness in Children Relief Fund. The 
fund would be financed by surcharges on premiums paid by insureds for 
their hcallh insurance policies. The amount of Ihe surcharge could not ex- 
ceed 5 pcrcenl of Ihe premium paid. Money from the fund would be 
devoted lo covering the costs of catastrophic illnesses of children. The bill 
defines a cataslrophic illness as any illness except for mental illness or 
developmental disability, the expenses for which are not covered by any 
other assistance or insurance and exceed 30 percent of the gross income of a 
family whose gross annual income is $100,000 or less, or 40 percent of the 
gross income of a family with over $100,000 a year. 
SB 59 Creates the Cataslrophic Health Insurance Fund and a New Jersey 
Catastrophic Health Insurance Underwriting Association. 

To be eligible lo receive cataslrophic health insurance benefits, an in- 
dividual would have to have a qualified insurance plan, and/or pay coin- 
surance in the form or a "personal resource payment." An individual with 
a comprehensive qualified plan (e.g. hospitalization, medical, and major 
medical) would have to pay a significantly lower coinsurance payment than 
would an individual with no health insurance coverage at all. 

Once having been declared eligible to receive cataslrophic benefits, an in- 
dividual would crllect from the fund. This fund would be established in- 
itially by a Slate appropriation. Thai portion of the fund which is used to 
pay benefits to individuals with privale carriers would be repaid to the State 
by means of reimbursement of the fund by the carriers who would all be 
members of the Underwriting Association. The carriers in turn, would be 
pcrmilled to pass the cost on to their subscribers by means of a surcharge. 

The claims eligible for payment by Ihe Underwriting Association would 
be submitted through a servicing carrier. The reimbursement rate would be 
the same as those established for nonprofit medical and hospital service cor- 
porations, unless a service is reimbursable which is not included in their rate 
structure. In this case, the Commissioner of Health would determine the 
reimbursement rate. 



5 



NEW MEXICO 
LAWS 

SB 26, Chapter 201, Laws ol 1984 Prohibits payment, under the Indigent 
Hospital Claims Act, for any costs when the patient is eligible for Medicaid. 
Also, clarifies procedure for hospitals and ambulances filing claims. 
STUDIES 

Currently, there are two groups studying the issue of health care for the 
indigent, either directly or as a component of cost containment. 

• The Statewide Health Coordinating Council has formed a special com- 
mittee (which includes non-SHCC members) called the Health Care Access 
Committee. 

• The Department of Human Services and the Department of Health and 
Environment have formed a joint study group called the Health Care Cost 
Containemnt Task Force which will address, among other health care 
issues, the problems of providing care to the medically indigent. 

• The State Health Planning and Development Bureau of the Department 
of Health and Environment funded a study prepared by the University of 
New Mexico, Bureau of Business and Economic Research. The report, 
Health Care Coverage and the Medically Indigent in New Mexico, was 
released February of 1984. 



NEW YORK 
BILLS 

AB 10097 Creates the New York Excessive Risk Health Assurance Pro- 
gram. This program modifies the existing Medicaid program by expanding 
Medicaid to include all persons regardless of categorical relationships, 
replacing the current spend-down provisions of the medically needy compo- 
nent of Medicaid and eliminating the current (nonfunded) catastrophic il- 
lness program. A federal waiver would be necessary for implementation of 
the program. 

A family whose annual income is less than 125% of the imputed annual 
public assistance grant is eligible to have 75% of their health care expenses 
reimbursed. A family shall have no cost sharing (i.e., 100% of their health 
care expenses reimbursed) when their expenses are in excess of 125% of the 
difference between projected family income and the public assistance grant. 

Conditions of eligibility includes coverage under an approved health in- 
surance policy available benefits, such as Medicare or veterans benefits. 
AB 3211-D Establishes the Unemployed Health Insurance Protection Plan 
of New York. The program would offer a basic health insurance benefit 



6 



plan to recipients of unemployment insurance. Coverage of benefits could 
not exceed the basic required services under the Medicaid Progrnm. 

The Insurance would be issued by a licensed insurer (or insurers) selected 
through a competitive bidding process. Premiums would be deducted from 
the unemployment check, and the imposition of deductibles and copays is 
authorized. In the event unemployemt insurance benefits cease due to ex- 
haustion of benefits, the individual may continue to pay the amount of the 
premium and extend coverage for an additional 60 days. 
SB 917 Creates the Pharmaceutical Assistance for the Aged program lor 
residents 65 years or older, and whose annual income is less than $7,500. No 
person is eligible until they have expended the sum of $100 for prescriptions 
and a $2 copay per person is required. 

AB 10242 Creates a program where every hospital and health care facility 
is required to provide, free of charge, regular visits to pregnant women 
whose income is 150% of the poverty level. In the third year of the pro- 
gram, the eligibility level shall be raised to 185% of the poverty level. 
SB 9447 Establishes an advisory board on health insurance for the 
unemployed to examine, evaluate and make recommendations concerning 
the scope, quality and cost of providing essential health insurance to the 
unemployed. 



OHIO 

LAWS 

HB 215 Establishes rules controlling the continuation of group health in- 
surance coverage upon the termination of an employee. Also, authorizes the 
formation of a voluntary association of insurers to offer health insurance to 
unemployed individuals or employed individuals who do not have such in- 
surance. 



OKLAHOMA 

LAWS 

HJR 1B02 Creates the Oklahoma Indigent Health Care Act to reimburse 
hospitals for services rendered to indigents. The program is financed 
through state and county revenues and administered through public care 
trust boards. 

Participation by the counties is voluntary. Counties eligible to be reim- 
bursed from the state fund must meet two requirements: I) passage of a 
county levy approved by a majority of the voters for the payment of in- 
digent health care expenses; and 2) creation of a public county indigent 



health care trust board on approval by a majority vole of a private county 
indigent health care trusl board. 

The bill defines Indigent as a person or head of household with.- I) insuffi- 
cient income (less than the poverty level) and Insufficient resources; 2) no 
form of third-party insurance coverage; or 3) the occurrancc of a 
catastrophic injury or illness resulting in medical expenses exceeding 50 per- 
cent of one's gross income exclusive of any insurance reimbursement during 
a 12-montli period. 

Participating hospitals are required lo establish a screening process to en- 
sure that persons entering the hospital arc not eligible for Medicaid or 
Medicare or other third parly coverage. 

Payments from the stale fund to all participating hospitals in the county 
shall be based on the rtnio thai each hospital's indigent health care rale 
related to the total Indigent health care rale for all participating hospitals in 
the county. 

HJR 1051 Presents a constitutional amendment, to be voted on by residents 
in a Statewide referendum, which would authorize an additional county ad 
valorem lax lo finance Indlgenl health care services. The tax could nol ex- 
ceed 3.5 mills on the dollar of the assessed valuation of all taxable properly 
in the counly and could be levied annually if approved bv a majority of 
voters In the counly. 



SOUTH DAKOTA 

LAWS 

SB 125 Establishes a catastrophic county poor relief fund lo be effective if 
50 counties in the state puss resolutions before December I, 1984, re- 
questing participation, Participating counties which have incurred hospital 
and other medical claims in excess of $20,000 for any individual eligible for 
counly poor relief may receive reimbursement from the fund. However, 
payments would be limited to 90 percent of any hospital or medical bills in 
excess of $20,000 during a calendar year. Each participating county's share 
of the rund would he computed using the following factors: l)the percent of 
the total population, minus individuals eligible for Medicaid, of Ihe par- 
ticipating counties in Ihe state, and 2) the percenl of the taxable value of the 
participating counties in Ihe state associated with the county as determined 
by the department of revenues. 
BILLS 

SB 179 Authorizes boards of counly commissioners lo enter into an in- 
surance contract lo provide payment for all or part of indigent medical ser- 
vices. The premium for Ihe contract may be paid for from counly poor 
relief funds. 



TENNESSEE 
LAWS 

HB 1909, Chapter 184, Private Laws ol 1984 Allows Tiplon Counly to create a 
perpetual trust fund for the purpose of assisting the medically indigent in 
paying for their inpatient and outpatient hospital and medical care. The 
fund would receive appropriations from the county legislative body and ex- 
penditures from the trust fund would be limited to the income derived from 
the principal, unless authorized by three-fourths of the legislative body. 

STUDIES 

• The Governor has appointed the Select Committee on Cost Containment 
to prepare a report on several health cost issues. It is expected that there will 
be coordination with the Department of Health and Environment's study, 
under contract with Vanderbilt University, on the uninsured in Tennessee. 
HJR 330 Directs the Department of Heallh and Environment and the 
Department of Commerce and Insurance to study the need for comprehen- 
sive/catastrophic health insurance in Tennessee and to analyze the options 
for implementation. A report to the General Assembly is due February 15, 
1985. 

BILLS 

HB 1392 Authorizes the adoption of specific guidelines which require 
hospitals requesting a bond issue to provide a set percentage of care for in- 
digent patients. 



TEXAS 
STUDIES 

• A 75-member Task Force on Indigent Health Care in Texas was ap- 
pointed by Ihe Governor, the Lieutenant Governor, and the Speaker of the 
House. The task force is conducting hearings around the state in an effort 
to address four principal topics: scope of service; eligibility criteria; ad- 
ministrative structure; and financing methods. The task force is to develop 
a set of legislative recommendations for the 1985 session of Ihe Texas 
Legislature. 

UTAH 

STUDIES 

HJR 5XX Directs the Legislative Management Committee to assign an in- 
terim committee to study the funding and role of the medically indigent in 
ihe state and make recommendations for legislative action in 1985. 
However, due to a crowded agenda for other studies, the indigient care issue 
may not be addressed. 



7 



VIRGINIA 

STUDIES 

HJR 129 Creates a joint subcommittee to study alternatives for a long-term 
state health care policy for the indigent. A report is to be presented during 
the 1985 legislative session. 

HJR 69 Establishes a joint subcommittee to study health insurance 
coverage available for people with significant risks and the feasibility of im- 
plementing a health insurance pooling mechanism. 
BILLS 

HB 878 Allows a locality participating under the State and Local 
Hospitalization Program to provide local funds for operation of a program 
of hospital and outpatient treatment and care for indigent and medically in- 
digent persons which exceeds the minimum requirements. 



WASHINGTON 

LAWS 

SB 4403, Chapter 288, Laws ol 1984 Amended the Washington State 
Hospital Commission Act in the following manner: 

1) Requires the Hospital Commission, in its annual report to the 
Legislature, to include data on the amount of charity care provided by each 
hospital, an analysis of the law's effect on the medically indigents' use of 
nonhospital settings, and an analysis of the law's effect on the resulting 
costs of the state's limited casualty program. 

2) Directs the Commission to establish, by rule, a definition of residual 
bad debt (for rate-setting purposes) and to adopt uniform criteria for identi- 
fying patients receiving charity care. 

3) Requires the Commission to compile data on charity care. 

4) Directs the Commission to assure that no hospital adopts admission 
practices which result in a significant reduction in the proportion of patients 
who have no third-party coverage and are unable to pay, or a significant 
reduction in the proportion of individuals admitted for inpatient services 
for which payment is, or is likely to be, less than the charges for such ser- 
vices. 

5) Adds to the certificate of need approval process, consideration of a 
hospital's level of charity care, as compared to the regional average. And, 

6) Allows the adoption of a hospital reimbursement mechanism which 
deals equitably with the costs of charity care. 



8 



Three charity care provisions of SB 440.1 were vetoed by the Governor. 
They were: 

1) Permission for hospitals to charge any payer at a rate less than those 
approved by the commission when the hospital granting such rates provides 
charity care at or above the regional average. 

2) Requirement that hospitals provide emergency or other medically 
ncccssnry services to any person who is in need of such services. And, 

3) Rejection of a certificate of need application when a hospital has not 
met the regional average level of charity enre. 

STUDIES 

• The Ad Hoc Advisory Committee on Uncompensated Health Care sub- 
mitted a report of findings and recommendations to the I cgislaturc on 
January 12, 1984. 



WEST VIRGINIA 
8ILLS 

HB 1744 Imposes as a condition of licensure that hospitals provide free or 
charity care equal to 5 percent of their gross business. 
SB 656, HB 1940 Provides for the creation of a charity and medically in- 
digent care pool for generating additonal stale matching funds to contribute 
to the state's Medicaid program and for financing health care lor the in- 
digent. Revenues for the fund would be derived from an annual one percent 
assessment on each acute care hospital's net patient revenue. 
SB 216, HB 1284 Creates a statewide health insurance program to assist low 
income people in the purchase of adequate health insurance coverage. 
Eligibility would be restricted to: I) those whose incomes arc less than 200 
percent of the federal poverty level; and 2) persons who arc generally not 
covered by federal or stale medical assistance programs. The program 
would be administered by the Commission of Human Services which is 
charged with establishing standards for a qualified health insuranc policy 
for the program. The bill would require that a qualified policy must adhere 
to at least the following standards: I) coverage for comprehensive major 
medical care; 2) minimum limit on the benefits payable; 3) $500 minimum 
out-of-pocket expense for recipients; and 4) encouragement of lower-cost 
alternatives. 

SCR 31 Requests a study on the problem of charity care funding in 
hospitals in the state. 



WISCONSIN 

LAWS 

AB 563 Directs the state to develop a model hcallh insurance plan. The 
Plan is to have two versions: one which would be offered hy Ihc private sec- 
tor, and the other by the state or jointly hy the stale and Ihc private sector. 

m i" m " S ' coma ' n Provisions for offering the plan to persons eligible 
lor Medicaid and lo other low-income persons, including single people with 
dependent children, unemployed persons, and those who cannol obtain 
health insurance through their place of employment. The plan must also 
contain a premium and cost-sharing schedule based on ability to pay. To the 
extent possible, payments should be on a prepaid capitation basis, with 
dirccl negotiation of payment rales with providers. 
AB 466, Act 386. Laws ol 1984 Permits any municipality or county to pur- 
chase health or dental insurance for unemployed persons residing in Ihc 
municipality or county who arc not eligible for Medicaid. 
BILLS 

AB 773 Adds procedural and informational requirements for hospitals 
notifying or billing municipalities or counties for emergency medical care 
provided under general relief. 

AJR 94 Requests the Legislative Council lo study the desirability and 
feasibility of including catastrophic hcallh care coverage in all hcallh care 
plans. 



9 



DECEMBER 1983 
ADDENDA AND ERRATA 



KANSAS 
Reimbursement 

add: 

• Reimburses for 3 levels ol partial hospitalization (MA) 
Administration & Management 

delete: 

• Begins use of HCFA 1500 claim form for all providers (MA) 
This was adopted in 1981. 

KENTUCKY 

Benefits: 

change: 

• Adds coverage to certain hospice services (MA) 

to: 

• Adds coverage of certain hospice services (MC) 
Reimbursement 

change: 

• Imposes ceiling of $350 for services... 
to. 

• Imposes ceiling of $365 for services... 
MINNESOTA 

Benefits 

cnange: 

• Increases to 30 days the maximum length of stay for treat- 
ment of alcoholism, chemical dependency, or drug addiction 
in a hospital or nursing home (SF 1234 LA) 

to: 

• Increases to 30 days the maximum length of stay for treat- 
ment of alcoholism, chemical dependency or drug addiction 
in a hospital or nursing home, that can be provided without 
prior authorization (SF 1234 LA) 



change: 

• Adds community health centers (SF 1234 LA) 

to: 

• Adds community mental health centers (SF 1234 LA) 

cnange: 

• Adds personal care attendant services (SF 724 LA) 

to: 

• Continues lunding ot personal care attendant services (SF 
724 LA) 

Reimbursement 

change: 

• Freezes practitioners' rates for state-only funded General 
Assistance Medical Care Program (MA) 

to: 

• Extends for 2 years practitioner reimbursement under the 
General Assistance Medical Care Program at 50th percentile 
ol 1978 UCR fees (SF 1234 LA) 

NOTE: 

SF 695 is now Session Laws 1983, Chapter 199 
SF 1234 is now Session Laws 1983, Chapter 312 
SF 490 is now Session Laws 1983, Chapter 151 

MONTANA 

Benelits 

add: 

• Expanded copays to all services except personal care ser- 
vices. Copays include $3 for IP hospital; $1 for OP hospital, 
$1 for most practitioners, $1 for home health, and $.50 lor 
therapies, drugs, and private duty nursing. Caps on copays 
include $66 per hospital admission and an overall cap equal- 
ing 5% of AFDC average payment for one adult (MA) 



NEVADA 

Benellts 

add: 

• Amended copay to exompl all under age 19 (MA) 

• Amended copay lo conlorm lo TEFRA (MP) 
Eligibility 

add: 

• Extended coverage lo llrsl-timo pregnant women (MA) 

• Went to lull calendar month tor high-Income institutional 
recipients, thereby reducing the number ol qualifying persons 
(MA) 

Reimbursement 

add: 

• Reduced rate lor OP hospital pathology to same as sole- 
source labs (MA) 

delote: 

• Roduces payments to LTC facilities 
Administration & Management 

change: 

• Established sole-source contracts tor covered lab pro- 
cedures within the Rono and Las Vegas area (MA) 

to: 

• Established sole-source contract lor covered lab pro- 
cedures within Ihe Reno and Las Vegas area, and eliminated 
pay to physicians lor lab work (MA) 

add: 

• Withdrew request for waiver regarding contracting with 
sole-source pharmacy (MA) 



OREGON 
Reimbursement 

delete: 

• Raises reimbursement rate tor podiatrists to 100% of max- 
imum tees paid to physicians tor same procedures (MA) 
change: 

• Eliminates separate payment for high-use oxygen tor nurs- 
ing home patients (MA) 

lo: 

• Limits payment to the provision of a concentrator in cases 
where a nursing home resident needs a high use of oxygen 
(MA) 

WEST VIRGINIA 
Benelils 

delete: 

• Imposes deductible of up to $75 on IP hospital services (LA) 

WISCONSIN 
Benefits 

add: 

• Imposes deductible ot up to $75 on IP hospital services (LA) 



Intergovernmental Health Policy Project 

George Washington University 



The Intergovernmental Health Policy Project serves a unique 
function in the development of the nation's health policy. It is 
the only university-based program in the country concentrating 
its research efforts exclusively on the health laws and programs 
of the 50 states. The Project provides assistance to stale ex- 
ecutive officials, legislators, legislative staff and others who 
need to know about important developments in other states. At 
the same time, the IHPP helps federal officials identify in- 
novative state health programs and specific state problems. 

To facilitate these information-brokering activities, the IHPP 
maintains direct links with state governmental agencies, slate 
legislatures, research centers, planning agencies, and interest 
groups throughout the country. Reliable, up-to-date informa- 
tion on health legislation and programs is obtained through 
IHPP's own network of knowledgeable health policy experts in 
each of the 50 states, as well as from its clearinghouse of all state 
health legislation. 

Through its newsletter, State Health Notes, research publica- 
tions, and conferences, the IHPP provides key health policy- 
makers with timely, comprehensive examinations of innovative 
state legislative activities and health programs. 

The Intergovernmental Health Policy Project is affiliated with 
the National Health Policy Forum, with which it works closely 
to identify issues of concern to state and federal policymakers. 
The National Health Policy Forum is a privately funded non- 
profit organization which provides in-service educational ex- 
periences to high level congressional, White House and executive 
agency specialists in health care. Both the IHPP and the Health 
Policy Forum operate under the auspices of The George 
Washington University in Washington, D.C. 

The programs and the services of the Intergovernmental 
Health Policy Project are made possible through a grant from 
the Office of Research and Demonstrations (ORD), Health Care 
Financing Administration, Department of Health and Human 
Services fHCFA Grant #lfi-P-98148/3-03). 

The Intergovernmental Health Policy Project 
2100 Pennsylvania Avenue, Northwest, Suite 616 
Washington, D.C. 20037 
(202) 872-1445 



State Medicaid Information Center 

The National Governors' Association 
Center for Policy Research 



The National Governors' Association, founded in 1908 as the 
National Governors' Conference, is the instrument through 
which the governors of the fifty Stales and the Commonwealth 
of Puerto Rico, the Virgin Islands, Guam, American Samoa, 
and the Northern Mariana Islands collectively influence the 
development and implementation of national policy ami apply 
creative leadership to state problems. The National Governors' 
Association membership is organized into eight standing com- 
mittees on major issues: Agriculture; Criminial Justice and 
Public Protection; Executive Management and Fiscal Affairs; 
International Trade and Foreign Relations; Human Resources; 
Energy and Environment; Community and Economic Develop- 
ment; and Transportation, Commerce, and Technology. Sub- 
committees that focus principal concerns of the governors 
operate within this framework. The Association works closely 
with the Administration and the Congress on state-federal policy 
issues from its offices in the Hall of the States in Washington, 
D.C. 

The National Governors' Association Center for Policy 
Research serves as a vehicle for sharing knowledge of innovative 
programs among the States and provides technical assistance to 
governors. The Center also serves governors by undertaking 
demonstration projects and by providing research and develop- 
ing policy options on a variety of crucial issues. 

The activities and publications of the State Medicaid Informa- 
tion Center arc made possible through a grant from the Office of 
Research and Demonstrations, Health Care Financing 
Administration, Department of Health and Human Services 
(HCFA Grant #!8-P-97923/3-2). 

State Medicaid Information Centet 
National Governors' Association 
444 North Capitol SI., N.W., Suite 250 
Washington, D.C. 20001 
(202) 624 5344