Evaluating Your State Medicaid Program

Every state’s Medicaid program is different, so developing a proactive policy agenda should start with an evaluation of current policies and processes. This tool, though not meant to be a checklist or comprehensive list of potential improvements, highlights key areas to consider.

  • Restrictions
  • Getting Covered
  • Staying Covered
  • Benefits
  • Access
  • Additional Services
  • Managed Care
  • Initiatives

Maximizing Eligibility and Avoiding Eligibility Restrictions

 

Cover lawfully residing immigrant children and pregnant women through Medicaid and CHIP

For more information and to see what your state does, click here
 

Increase eligibility and/or eliminate or reduce asset tests for seniors and people with disabilities, and where resource tests apply, allow for self-attestation

For more information and to see what your state does, click here
 

Provide 12 months of post-partum coverage

 

Expand children’s Medicaid or CHIP eligibility above the minimum federally required levels

To see your state’s eligibility threshold for children, click here
 

Expand Medicaid eligibility to adults under age 65

To see your state’s eligibility threshold for adults, click here

Making It Simple to Enroll

 

Allow people to enroll, report changes, and submit information upon renewal by phone and/or through an online platform that is accessible on mobile devices

For best practices, click here and here
 

Allow people to apply for Medicaid and other programs, like SNAP, at the same time

 

Maximize use of electronic databases to verify eligibility and minimize documentation requests

For more information on verifying Medicaid eligibility, click here
 

Enable people involved with the criminal justice system to maintain Medicaid coverage

For policy options and to see what your state does, click here and here
 

Maximize use of presumptive eligibility

For more information, click here
 

Conduct “real-time” (within 24 hours) eligibility determinations

For best practices, click here

Making It Simple for Eligible People to Stay Enrolled

 

Provide 12 months of continuous eligibility to children

For more information on continuous eligibility and to see whether your state is implementing it for children, click here
 

Provide 12 months of continuous eligibility to adults

Continuous eligibility is a state option for children but requires a section 1115 waiver for adults, and only Montana and New York currently implement the policy
 

Minimize requests for information during the eligibility period

 

Conduct a streamlined renewal process, including ex parte renewals to the greatest extent possible

For best practices, click here
 

Contact beneficiaries through multiple means, including text, when action is needed

For best practices on beneficiary communication, click here; for best practices on text messaging, click here

Providing All the Benefits That People May Need

 

Adult dental, vision, and other optional benefits

To see what benefits your state provides, click here (for dental) and here (for vision)
 

Comprehensive home- and community-based services without waiting lists

For more information on home- and community-based services, click here
To see how your state compares with other states with respect to waiting lists, click here
 

Prescription drugs without non-clinical restrictions (e.g., prescription limits)

To see whether your state imposes prescription limits, click here
 

No other non-clinical restrictions (e.g., limits on bed days in health care facilities)

To see whether you state limits bed days in health care facilities, click here

Facilitating Access to Needed Care

 

No premiums or cost-sharing

To see what your state does, click here and here
 

Accessible, up-to-date provider directories

 

Non-emergency medical transportation

To see whether your state has obtained a waiver to drop this benefit, click here and here
 

Three months of retroactive coverage

To see whether your state has obtained a waiver to drop this protection, click here
 

Language access services for people with limited English proficiency

To see what your state does, click here
 

Ensure children’s access to Medicaid’s Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit

For more information, click here
 

School-based health services for all eligible children

For more information, click here
 

Maximize telehealth

For more information, click here
 

Make changes to respond to the COVID-19 crisis

For more information, click here and here

Providing Additional Services for People with Specific or Complex Needs

 

Health homes for people with chronic physical or behavioral health conditions

For information on what your state does, click here and here
 

A full continuum of care for people with substance use disorders and mental health conditions

For information on what your state does, click here
 

In-reach and coordination services for people involved with the criminal justice system

For more information, click here and here
 

Tenancy-related services for people who are unstably housed

For more information, click here and here

Holding Managed Care Plans Accountable
(if your state provides coverage through managed care plans)

 

Regularly report quality measures stratified by health plan and population demographics

For more information, click here and here
 

Require plans to meet a quality measurement threshold (e.g., the national average)

For more information about managed care quality requirements, click here
 

Establish comprehensive network adequacy standards

For more information, click here
 

Regularly report data on fair hearings and appeals

For more information, click here and here
 

Publicly post annual model contracts

 

Require remittances from plans that fail to meet their annual medical loss ratio

For more information and to see what your state does, click here

Initiatives to Improve the Health Care Delivery System

While there are no simple, off-the-shelf approaches in this area, states are experimenting with a variety of options, including:

 

Testing new ways to pay for care, such as bundled payments for certain conditions

 

Identifying ways to improve care for specific conditions or groups, such as reducing maternal mortality, racial/ethnic disparities in access or outcomes, etc.

 

Investing in infrastructure to coordinate care across providers within the health care system (e.g., behavioral health) and across other sectors (e.g., housing, nutrition, child welfare)