Utah Per Capita Cap 1115 Waiver Summary

On May 31, 2019, Utah released its 1115 waiver proposal, “Per Capita Cap.” This waiver requests authority to implement the provisions of Senate Bill 96 “Medicaid Expansion Adjustments”, which passed during the 2019 Utah legislative session.  Provisions of the waiver include implementing a per capita cap, seeking enhanced Federal Medical Assistance Percentages (FMAP) for the state’s partial Medicaid expansion, implementing a Medicaid lock-out for intentionally violating Medicaid eligibility rules, requesting federal funding to provide housing-related services and supports, and preventing hospitals from making presumptive eligibility determinations for the expansion population.

This waiver application is a follow-up to the recently (March 29, 2019) approved Utah 1115 waiver, which implemented a partial Medicaid expansion, Medicaid work requirements, and waived the Medicaid institution for mental disease (IMD) exclusion.

The Utah Department of Health, Division of Medicaid and Health Financing (DMHF) will hold public hearings to discuss the new 1115 application.  DMHF will also accept public comments regarding this demonstration application during the 30-day comment period from May 31, 2019 to June 30, 2019.

The below summarizes key points of the waiver.

Waiver Elements

Partial Expansion and Caps

Back in April we reported that Utah received CMS approval for a partial Medicaid expansion. On March 29, 2019, Utah became the first state to receive CMS approval of a partial Medicaid expansion. The ACA expanded Medicaid to the new adult group to individuals with incomes up to 138 percent of the federal poverty level (FPL). However, Utah only has expanded Medicaid to 100 percent FPL for the new adult group.

The waiver approved in March also outlined that should the projected costs for the expansion population exceed annual state appropriations, the state will be permitted to close enrollment. When enrollment is closed, the state will continue to accept and review applications to determine whether applicants are eligible for Medicaid on any other basis. However, if that individual is only eligible for Medicaid through the expansion, they will be denied (there is no waitlist, or contacting individuals on when to enroll again). The waiver states that this expansion will end January 1, 2021.

Under the March 29 approved waiver, the state received a 70 percent federal match for the expansion population. That approval outlined that the state would follow-up with a second waiver to receive the enhanced 90 percent federal match for the expansion population. The waiver that was submitted on May 31 does just that – requests to allow the state to receive the full FMAP allowable, which is 93 percent for 2019 and 90 percent for 2020 and each year thereafter for the expansion population.

Additionally, the May 31 wavier application proposes a per capita cap methodology for the expansion population. Specifically, Utah is requesting that the increased FMAP received for the expansion would be available up to a limit set by a per capita cap methodology. Utah proposes to work with CMS to establish a per enrollee base amount for the first demonstration year with trending for future demonstration years.

There will be separate per capita caps for three distinct enrollment groups: 1) adults with dependent children; 2) adults without dependent children; and 3) targeted adults and members residing in an IMD primarily to receive short-term residential treatment for substance use disorder (SUD). The per member per month (PMPM) rate for year one (2020) for adults with dependent children is $649.72.The PMPM rate for year one (2020) for adults without dependent children is $755.12. The PMPM rate for year one (2020) for targeted adults and members residing in an IMD primarily to receive short-term residential treatment for SUD is $1,761.48. Additionally, the state also proposes to use a 4.2 percent growth rate for per capita caps from demonstration year one to demonstration year two.

Furthermore, the state requests the opportunity to review estimates and request that a certain percentage or amount of medical assistance expenditures be excluded from per capita cap calculations if the state undergoes a “special circumstance,” such as public health emergency, natural disaster, major economic event or other waivers approved by CMS that affect the population.

Medicaid Lock-Outs

Through the waiver, Utah proposes to apply a six-month ineligibility period if an individual commits an intentional program violation to become or remain eligible for Medicaid. An intentional violation includes, but is not limited to, knowingly making false or misleading statements, misrepresenting, concealing or withholding facts, violating program regulations, posing as someone else, or not reporting a required change within 10 days after the change occurs. Additionally, the state will investigate if there was Medicaid overpayment due to an intentional program violation.

An individual can request to receive continued benefits if they decide to appeal the intentional program violation decision. If the decision is upheld, and the individual requested continued benefits, an overpayment of Medicaid benefits will be assessed for the months the individual continued to receive Medicaid.

Housing Services

Through this waiver, Utah requests authority to provide housing supports for the expansion population. Specific services the state intends to provide include: 1) Tenancy Support Services; 2) Community Transition Services; and 3) Supportive Living/Supportive Housing Services. It is important to note that none of these include room and board.

12-Months Continuous Eligibility

Currently, Utah provides 12-month continues eligibility for the Targeted Adult Population, which includes the chronically homeless, individuals involved in the justice system and in need of substance use or mental health treatment, and individuals needing substance abuse or mental health treatment. This application expands 12-month continuous eligibility to the expansion population.

Changes that occur during the certification period will not affect eligibility during the period of continuous eligibility, except when a beneficiary: turns age 65; moves out of state; fails to apply for other benefits; becomes institutionalized; is determined eligible for another Medicaid program; fails to comply with the community engagement requirement during the three-month participation period; faces closure due to lock-out for committing an intentional program violation; commits fraud; or fails to enroll in employer-sponsored insurance.

Presumptive Eligibility

Utah proposes to not allow a hospital to determine presumptive eligibility for the adult expansion population. (Currently, Utah does not allow presumptive eligibility determinations for the Targeted Adult Population, which includes the chronically homeless, individuals involved in the justice system and in need of substance use or mental health treatment, and individuals needing substance abuse or mental health treatment.)