Northern Mariana Islands (CNMI) Medicaid Overview

“The Medicaid program in the Commonwealth of the Northern Mariana Islands (CNMI) differs from Medicaid programs operating in each of the 50 states and the District of Columbia. Some of the key differences are:

CNMI became a territory in 1978 and its Medicaid program was established in 1979. It is a 100% fee-for-service delivery system with one hospital servicing the territory. There are no deductibles or co-payments under the CNMI Medicaid program. Unlike states, CNMI residents are not eligible for Medicaid Part D low-income subsidies; instead the Medicaid program receives an additional grant through the Enhanced Allotment Plan (EAP) which must be utilized solely for the distribution of Part D medications to dual-eligible or low-income Medicare eligible individuals.
CNMI operates its Medicaid program under a broad waiver granted under the authority of Section 1902(j) of the Social Security Act. This provision allows the Secretary to waive or modify any requirement of Title XIX, in regards to CNMI’s Medicaid program, with the exception of three: the territory must adhere to the funding cap set under Section 1108 of the Act; the territory must adhere to the statutory Federal Medical Assistance Percentage (FMAP); Federal medical assistance payments may only be made for amounts expended for care and services described in a numbered paragraph of section 1905(a).
Effective October 1, 2017 CNMI elected to allow individuals whose income is in excess of the established income criteria to spend-down to become Medicaid-eligible. Additionally, effective January 1, 2021 CNMI elected to cover otherwise eligible individuals who lawfully reside in CNMI in accordance with the Compacts of Free Association (COFA) between the US and Micronesia, the Marshall Islands and Palau.
Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. Over the past decade Congress has temporarily increased federal funding for the territories’ Medicaid Programs via a number of specific statutory provisions. For federal fiscal year 2021 CNMI’s ceiling is $62.3 million.
Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in CNMI the FMAP is applied until the Medicaid ceiling funds and any other specified federal funds are exhausted. The statutory FMAP rate increased to 55%, effective July 1, 2011. Starting in January 2014 Congress has temporarily increased the FMAP along with federal funding, bringing CNMI’s FMAP to 83% for federal fiscal year 2021.”

Links:

Northern Mariana Islands Medicaid Overview

Guam Medicaid Overview

“The Medicaid program in Guam differs from Medicaid programs operating in each of the 50 states and the District of Columbia. Some of the key differences are:

Guam became a territory in 1950 and its Medicaid program was established in 1975. It is a 100% fee-for-service delivery system with one hospital currently servicing the territory. There are no deductibles or co-payments under the Guam Medicaid program. Guam’s Medicaid program does not administer a Medicare Part D Plan; the Medicaid program receives an additional grant through the Enhanced Allotment Plan (EAP) which must be utilized solely for the distribution of Part D medications to dual-eligibles.
Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $268,343,113 in Medicaid funding to Guam.
Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in Guam, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing Guam’s FMAP to 57.2%.

Medicaid-Marketplace Overview
Guam was awarded $24,436,001 million for its Medicaid program in lieu of establishing a health marketplace. Guam must exhaust its Affordable Care Act (Section 2005) allotment prior to using these funds.”

Links:

Guam Medicaid Overview

Rhode Island Comprehensive Demonstration Project (Section 1115) Renewal

“On July 1 1, 2018, Rhode Island submitted an application for a five-year renewal of its current section 1115 demonstration “Rhode Island Comprehensive Demonstration,” along with approval of modifications of the demonstration that would apply during the extension period. The purpose of the state’s proposal is to support the continuation of Rhode Island’s Medicaid program and to add new programs discussed below. The state will continue its home and community-based services (HCBS) component to provide services similar to those authorized under sections 1915(c) and 1915(i) of the Act to individuals who need HCBS either as an alternative to institutionalization or otherwise based on medical need. Effective January 1, 2019, the existing services will continue under the demonstration and be obligated to adhere to HCBS guidelines, policies, and reporting procedures. Any new HCBS requests the state would like to implement after January 1, 2019, will be authorized undersections 1915(c) and 1915(i).”

Links:

Rhode Island Comprehensive Demonstration Project (Section 1115) (PDF)

New Mexico Centennial Care 2.0 1115 Medicaid Demonstration Extension

“This approval is effective January 1, 2019 through December 31, 2023. CMS’ s approval is subject to the limitations specified in the attached waiver authorities, expenditure authorities, Special Terms and Conditions (STCs), and subsequent attachments. The state may deviate from the Medicaid state plan requirements only to the extent those requirements have been listed as waived or as not applicable to expenditures or individuals covered by expenditure authority…

Employment Supports will be provided by staff at current or potential work sites. When supported employment services are provided at a work site where persons without disabilities are employed, payment is made only for the adaptations, supervision and training required by members receiving services as a result of their disabilities but does not include payment for the supervisory activities rendered as a normal part of the business setting.”

Links:

New Mexico Centennial Care 2.0 1115 Medicaid Demonstration Extension (PDF)

New Mexico Report Legislating for Results: Policy and Performance Analysis (2019)

“One of 14 states without institutions for individuals with intellectual or developmental disabilities, New Mexico serves this population through a system of home- and community-based services funded through two main Medicaid programs administered by the Human Services Department (HSD) and operated primarily through the Department of Health (DOH). A 2018 LFC evaluation of these programs found growth in per-client costs and a lengthening waiting list are outpacing the state’s ability to fund and provide services. In FY17, about 3,500 people received services through the traditional developmental disabilities (DD) waiver program, while another 1,400 received services through the self-directed Mi Via program. Both provide services not usually covered by Medicaid under federal waivers of existing rules. The list of eligible individuals waiting for services, meanwhile, totaled roughly 3,900. The evaluation found increased service utilization, client movement from the traditional DD waiver program to Mi Via, and changes to how client service plans and budgets are developed have all contributed to rising costs. The average cost of an individual enrolled in the DD waiver program grew by 17 percent, to $78,575, between FY14 and FY17, while total enrollment fell by 13 percent. Meanwhile, budgets for Mi Via clients are approaching their annual individual caps, and cost growth in both waivers is on pace to potentially violate federal cost neutrality requirements by FY27.”

Links:

New Mexico Report Legislating for Results: Policy and Performance Analysis (PDF)

Arkansas HCBS 1915c Technical Guide

“These instructions provide information to assist states in completing the Application for a 1915(c) Home and Community-Based Services (HCBS) Waiver, including changes implemented through November 2014…This guidance is intended to improve understanding of applicable Federal policies and their implications for the design and operation of a HCBS waiver.” The guidance includes service definitions on supported employment, customized employment and other services and resources for people with disabilities seeking employment.

Links:

Arkansas HCBS 1915c Technical Guide (PDF)

Indiana Home and Community-Based Services Provider Manual

“As a division of the Indiana Family and Social Services Administration (FSSA), the Division of Disability and Rehabilitative Services (DDRS) has two overarching responsibilities for children and adults with physical and cognitive disabilities:

Facilitate partnerships that enhance the quality of life.
Provide continuous, life-long support.

The Bureau of Developmental Disabilities Services (BDDS) and the Bureau of Quality Improvement Services (BQIS) are under the DDRS.”

Links:

Indiana HCBS Provider Manual

Wisconsin DHS Community Recovery Services Provider Resources

“The information on this page is for agencies providing and interested in providing Community Recovery Services (CRS).

CRS transitioned from the Medicaid 1915(i) State Plan Amendment to the 1905(a) State Plan Amendment in 2018. This began the identification of CRS as a psychosocial rehabilitation program.”

Links:

Wisconsin DHS Community Recovery Services Provider Resources

Delaware Medicaid Buy-In Study Group SCR 70 Study Group Final Report

“This report provides a summary of the Study Group’s activities through the sixth meeting held on December 12, 2018. Additionally, to facilitate continued discussion within the Study Group, this report contains preliminary recommendations that Delaware should further explore, including developing a federal Section 1332 Waiver application to implement a State-sponsored reinsurance program for the purposes of stabilizing the individual health insurance Marketplace, reducing individual health insurance premiums and increasing access to more affordable health insurance for Delawareans.”

Links:

Delaware Medicaid Buy-In Study Group SCR 70 Study Group Final Report
Delaware Medicaid Buy-In Study Group Final Report (PDF)

New York State Statewide Transition Plan (HCBS)

“DOH operates the following 1915(c), waivers in addition to overseeing our sister agencies and offices that operate other 1915(c) waivers as the State’s Medicaid agency.
•Long Term Home Health Care Program Waiver2
•Nursing Home Transition and Diversion (NHTD) Waiver
•Traumatic Brain Injury (TBI) Waiver
•Care at Home Waivers I and II

In addition, as noted above, New York State offers significant home and community-based LTSS through our Medicaid state plan, as well as under the NY Partnership Plan 1115 Demonstration Waiver. The rule does not apply to state plan services outside of 1915(i) and 1915(k) authorities. However, CMS has indicated that it expects New York State to address the application of the HCB Settings rule to all HCBS provided through its 1115 Demonstration in this Statewide Transition Plan. Finally, New York State implemented the Community First Choice Option (CFCO) – 1915(k), with an effective date of July 1, 2015, with the understanding that such services would not be provided in congregate or provider-owned settings until these options are assessed and remediated, if necessary, through the Statewide Transition Plan period.”

Links:

New York State Statewide Transition Plan (HCBS) (2023, PDF)