Highlight on Maine: Able-bodied MaineCare recipients could be subject to more stringent requirements

“Able-bodied adults” would be subject to work/education requirements and a lifetime limit of five years under changes Mary Mayhew, director of the Maine Department of Health and Human Services, proposed to Maine’s Medicaid program, MaineCare. In a letter to HHS Secretary Tom Price, Mayhew said she would be seeking the changes in a forthcoming formal 1115 demonstration waiver request.

Mayhew’s letter comes at the heels of a referendum campaign to expand Medicaid in Maine at, according to Mayhew, a cost of $400 million over the next five years. A second motivation is the apparently sympathetic Trump Administration, which has proposed replacing Medicaid with block grants.

Mayhew said that the state has expanded its Medicaid program over decades, resulting in the use of hundreds of millions of state dollars “to turn Medicaid into an entitlement program for working-age, able-bodied adults.” MaineCare serves 270,000 individuals, just over 20 percent of Maine’s population, which, Mayhew said, represents a 22 percent reduction in enrollment since 2011.

Mayhew’s Medicaid proposals include the following:

  • work or education requirements for able-bodied adults in the Medicaid program, similar to the work requirements for Temporary Assistance for Needy Families (TANF) or Able-Bodied Adults Without Dependents (ABAWDs) in the Supplemental Nutrition Assistance Program (SNAP);
  • a five-year lifetime limitation on able-bodied adults’ eligibility for Medicaid;
  • limiting non-emergency transportation (NET) to situations where the underlying service to or from which individuals are being transported is a required Medicaid service and requiring them to access existing transportation resources before accessing NET;
  • requiring monthly premiums for adults who are able to earn income;
  • requiring monthly coinsurance of a set amount (approximately $20) for all members, cost-sharing of $20 for using the emergency department, and fees for missed appointments;
  • applying a reasonable asset test to Medicaid; and
  • waiver of the retroactive coverage of services incurred during the 90 days before Medicaid eligibility.


Medicaid fills a space for children with special health care needs

Medicaid is the sole source of coverage for 36 percent of children with special health care needs, according to a Kaiser Family Foundation (KFF) Issue Brief. Public insurance, like Medicaid, is important for many children with special health care needs because the Medicaid program covers medical and long-term care services that are either not covered or subject to limited coverage through private insurance. The proposed restructuring of Medicaid financing would likely impose limits on the scope of benefits available to all Medicaid beneficiaries. The KFF believes that Medicaid reform should carefully evaluate the potential impact on children with special health care needs.

Special Health Care Needs

HHS reports that nearly 20 percent of all U.S. children under 18 years of age have special health care needs. Additionally, one in five U.S. families has a child with a special health care need. HHS defines special health care needs as applying to children who  “have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.” Special health care needs stem from conditions including Down syndrome, cerebral palsy, depression, anxiety, and autism. Children falling under the definition have multiple and varied needs. For example nearly 70 percent of children with special needs have difficulty with bodily functions such as breathing, swallowing, or chronic pain. Children with special health care needs often have conditions which require nursing, therapy, and mental health counseling services.


The majority (73 percent) of children with special health care needs live in low or middle-income families. This means that 73 percent of children with special health care needs live in families with incomes below 400 percent of the federal poverty level. Of the 11.2 million children with special health care needs, 59 percent are white, 16 percent are black, 17 percent are Hispanic or Latino, and 8 percent fall into other racial or ethnic categories.  Forty-one percent of children with special health care needs are between 12 and 17 years old, 39 percent are between six and 11 years old, and 21 percent are between zero and five years old.


The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) required states’ Medicaid programs to cover children in families with incomes up to 138 percent of the federal poverty level. However, all states expanded financial eligibility for children above that level. As of January 2017, the median eligibility for Medicaid and CHIP children is 255 percent of the FPL. States may also make children who receive federal Supplemental Security Income (SSI) benefits eligible for Medicaid. Such children reside in poor families and are disabled in a way that severely limits their ability to function at home, school, and in the community.


Regardless of whether a state chooses to cover such services for adults, children are eligible for Medicaid’s Early and Periodic Screening Diagnostic and Treatment (EPSDT) benefit, which includes regular medical, vision, hearing, and dental screenings as well as other services necessary to “correct or ameliorate” physical or mental health conditions. Additionally, because private insurance is designed to meet the health care needs of a generally healthy population, Medicaid can fill the gap to provide care related to more intensive and chronic needs.


Medicaid provides a board scope of services and coverage to children with special health care needs. For many families, Medicaid serves as an important source of insurance and a means to fill gaps presented by inadequate private insurance. As a result, lawmakers should be cautious when evaluating Medicaid reforms to consider the impact such restructuring could have on children with special health care needs.

Expanded pharmacist scope of practice can improve access to care

Pharmacists are permitted to dispense drugs based on prescriptions they initiate, standing orders issued by the state, or collaborative practice agreements (CPA) with licensed prescribing providers. The Center for Medicaid & Chip Services (CMCS) within CMS encouraged states to provide flexibility to pharmacists to prescribe, modify, and monitor drug therapy for beneficiaries that may not have adequate access to care.

Pharmacy scope of practice

States establish the scope of practice for each type of licensed provider within the state through legislation or by a state department. Pharmacy scopes of practice are typically tailored to meet the public health needs of a jurisdiction or specific institution, and CMCS noted that providing the power to dispense drugs under certain arrangements, such as pharmacists’ prescriptions, can be an important tool for addressing national public health challenges.

Necessity for some populations

Allowing pharmacists to initiate their own prescriptions provides another access point to important drugs. Medicaid beneficiaries may not have established a relationship with a primary care provider, but may be able to obtain prescriptions more easily from a nearby pharmacy. Providing access to more medications through these channels may also result in decreased wait times, encouraging beneficiaries to pursue the treatment they need.

Timely access to life-saving drugs and other therapies

The informational bulletin presented the opioid epidemic as an opportunity for pharmacists to save lives. The opioid overdose reversal drug, nalaxone, prevents or reverses overdose effects, such as sedation and respiratory depression. In order to ensure that an overdose victim resumes normal breathing, Naloxone should be administered quickly. In most states, naloxone can only administered under a prescription or medication order, and it is typically provided by emergency responders either in an ambulance or emergency room. However, 40 states allow pharmacists to dispense naloxone under standing orders from licensed providers or by the states’ top medical officials.

California and New Mexico have allowed pharmacists to provide tobacco cessation therapy, such as nicotine replacement. The effect of allowing pharmacists to initiate, modify, and manage this treatment has resulted in an improved patient experience, including adherence to the therapy.

Pharmacist services include the provision of flu shots in a community pharmacy in an effort to avoid an influenza epidemic. Additionally, although some emergency contraception pills are available over the counter, prescriptions are required for Medicaid and third-party payer reimbursement. If a pharmacist is unable to dispense emergency contraception under a standing order or expanded scope of practice, these beneficiaries must first contact an authorized prescriber.

Managed care for long-term services working for states

Using section 1115 waivers to provide Medicaid managed long-term services and support (LTSS) allows states to expand access to home- and community-based services (HCBS) to beneficiaries at risk of institutionalization. The Kaiser Family Foundation (KFF) surveyed enrollment, spending, and program policies for the 11 states using managed LTSS in 2015, and found that while states used these waivers in an effort to improve administration efficiencies, most of the states did not pursue this method in an attempt to make costs more predictable.

Managed care

States that use managed care for LTSS contract with private health plans, paying these plans a set monthly rate per member. Spending on LTSS as a percentage of all Medicare spending is growing quickly, from 5 percent in 2009 to 15 percent in 2014. In response to this growth, CMS included LTSS provisions in recent revisions to Medicaid managed care regulations (see Final rule modernizes Medicaid managed care, April 26, 2016). States using this payment method are now required to identify and comprehensively assess enrollees with LTSS needs and create stakeholder advisory groups to oversee LTSS programs, while plans must comply with person-centered planning regulations. Even in light of these new responsibilities, states are using managed care to authorize HCBS for multiple populations and add in other Medicaid initiatives in order to streamline coordination.


The KFF analysis revealed some differences in states’ approaches and results in using managed care for LTSS. Most waivers expand financial eligibility for HCBS, while six of the states expand eligibility for HCBS to those who are “at risk” of institutionalization, attempting to prevent the need for costly future services by allowing beneficiaries to remain in their homes. The majority of LTSS waiver beneficiaries in the nine states reporting enrollment by setting were served in the community, but three of 11 states reported an HCBS waiting list. Almost all states require plans to cover a wide range of benefits, including nursing facilities, acute and primary care, and behavioral health services.


The KFF noted that states’ concerns about implementation could inform policymakers considering these programs in the future. In particular, the growing number of seniors and beneficiaries with disabilities, combined with the shortage of LTSS workers, has caused apprehension about keeping up with the pace of needed services. Despite this looming issue, the KFF believes that states will continue to choose managed care to provide LTSS.