States of Innovation: July 2024
Throughout the month of July, states were driving efforts to improve healthcare affordability. Oregon implemented a Basic Health Program to provide free health coverage to an estimated 100,000 low-income residents, while Colorado and Pennsylvania addressed rising drug costs. Meanwhile, several states took action on the issue of medical debt, including Illinois, New Jersey and Virginia, which announced they are prohibiting the reporting of medical debt to consumer reporting agencies; Illinois and North Carolina are canceling existing medical debt for low-income consumers, and Vermont implemented financial assistance policies to protect against future debt.
To expand coverage for non-citizen populations, Connecticut increased the age limit for the state-funded coverage program for non-citizen children effective July 1, and Washington implemented a new coverage program for people who do not qualify for traditional Medicaid due to their immigration status.
Also in July, states sought to engage the community and advance health equity. California partnered with Black media outlets, including community-based leaders, to discuss new Medi-Cal benefits, and Delaware began providing health equity training for providers and public health workers. Other states took steps to increase access to maternal health, such as New Jersey, which proposed rules to require implicit and explicit bias training for providers of perinatal treatment and care to pregnant persons.
States took steps to support mental and behavioral health, including Montana and Washington, while North Carolina and New Mexico strengthened services for children and youth. Lastly, July saw many states seek or receive approval from the Centers for Medicare & Medicaid Services (CMS) for waiver amendments and requests, including five states approved to provide pre-release services to justice-involved individuals: Illinois, Kentucky, Oregon, Utah and Vermont.
Affordability
Colorado has entered into a value-based pharmacy contract to address rising drug costs for Medicaid enrollees. The Colorado Department of Health Care Policy & Financing executed its fifth pharmaceutical value-based contract. This latest contract is with Sanofi for Dupixent, an injectable biologic medication approved to treat multiple diseases. Clinical outcomes will be monitored by the University of Colorado Skaggs School of Pharmacy, and if the clinical outcomes do not meet preselected targets, Sanofi agrees to reimburse part of the upfront cost.
Oregon implemented a Basic Health Program. Beginning July 1, Oregon began offering free health coverage to people in more income categories through a new benefit called the Oregon Health Plan (OHP) Bridge, the state’s Basic Health Program, for people with incomes between 138% and 200% of the federal poverty level (FPL). The name references the goal to “bridge” the health coverage gap between people who have traditional Medicaid and people who have Marketplace coverage. OHP Bridge will have no member costs and an estimated 100,000 people are anticipated to qualify for the program.
Pennsylvania is increasing oversight of pharmacy benefit managers. Governor Josh Shapiro signed HB1993 into law, providing stronger protections for patients in Pennsylvania and increased regulatory oversight of pharmacy benefit managers (PBMs). HB1993 grants the Pennsylvania Insurance Department the authority to regulate PBM practices and contains several protections that will result in lower out-of-pocket costs for prescription medication.
Washington is examining policy options to reduce the growth of healthcare costs. The Office of the Insurance Commissioner issued a report studying five potential policy options that could make healthcare more affordable in Washington. The report, delivered to the Legislature, uses pricing data to provide an economic and actuarial analysis of each policy option that estimates savings for consumers, organizations and the state’s economy.
Community Engagement
California is partnering with Black media outlets to share information about Medi-Cal. The California Department of Health Care Services (DHCS) partnered with California Black Media to host six community events throughout the month of July. DHCS leadership and representatives from Medi-Cal managed care plans met with newspaper publishers as well as business, faith, and community-based leaders in the Black community to discuss new Medi-Cal benefits and services and how Black media outlets can help share information with Medi-Cal members and their families.
For states interested in learning more about how to effectively engage individuals with lived experience, see the SHVS issue briefs Transformational Community Engagement to Advance Health Equity and State Examples of Medicaid Community Engagement Strategies: Two Case Studies.
Coverage for Non-Citizen Populations
Connecticut expanded health coverage for non-citizen children. Connecticut increased the age limit for the state-funded coverage program for non-citizen children who do not qualify for traditional Medicaid or Children’s Health Insurance Program (CHIP) coverage due to immigration status. Beginning July 1, eligibility for the program expanded from age 12 to age 15. Children who are enrolled in the program prior to age 16 may be eligible for continuous enrollment through age 18.
Washington implemented a new health coverage program for low-income, non-citizen residents. The Washington Health Care Authority established Apple Health Expansion, a program designed to provide full-scope coverage to people age 19 or older who do not qualify for other Apple Health programs based on their immigration status. The enrollment limit for Apple Health Expansion has been met for all age groups.
For more information on how states are expanding health coverage to non-citizens, see the SHVS expert perspective which includes an interactive map, State-Funded Affordable Health Coverage for Non-Citizen Populations.
Health Equity
Connecticut is establishing an office to promote equity and inclusion within state government. Governor Ned Lamont signed an executive order directing the establishment of the Connecticut Office of Equity and Opportunity. The Office will be led by a chief equity and opportunity officer who will be responsible for coordinating a number of activities, including developing statewide diversity, equity, and inclusion benchmarks and measures of progress and providing guidance to state agencies on how to engage and incorporate the perspectives of under-resourced communities.
Delaware is providing health equity professional development training for clinical and public health workers. The Delaware Division of Public Health is providing health equity training through the Health Equity Institute of Delaware (HEIDE). Led by the Office of the Medical Director and Office of the Chief Health Equity Officer, HEIDE helps providers and public health workers approach their work from a health equity perspective. The training will cover topics such as the health equity implications of climate change, sexual and reproductive health, mental health services, and dental care.
New Jersey proposed rules to require implicit and explicit bias training for certain healthcare providers. The Division of Consumer Affairs announced proposed rules that would require physicians, nurses, and midwives who provide perinatal treatment and care to pregnant persons in New Jersey to undergo implicit and explicit bias training. The training is intended to address biases that negatively impact the quality of care delivered by healthcare providers to women of color during pregnancy, labor, delivery, postpartum, and neonatal periods. A similar proposed rule for physician assistants was published on June 17, 2024.
SHVS has a resource page that serves as an accessible one-stop source of information on health equity for states. Also see SHVS’ Health Equity Impact Tool, which was designed to benchmark how state health agencies’ work impacts health equity and identify broad strategic equity goals which can be used to generate an action plan.
Maternal Health
New Jersey is investing in maternal health initiatives. Governor Phil Murphy signed the Fiscal Year 2025 budget into law, which includes a total of over $34 million to advance nine different recommendations in the Nurture NJ Maternal and Infant Health Strategic Plan. This investment includes: $23 million to expand Family Connects NJ, the statewide universal nurse home visitation program; $3.2 million for the operation of the newly established Maternal and Infant Health Innovation Authority; $2.9 million to become the first state in the nation to cover delivery fees for online WIC purchases; and more.
Illinois is requiring coverage of mental healthcare for individuals who have experienced a miscarriage or stillbirth. Governor JB Pritzker signed legislation requiring insurers to cover mental healthcare for people following a miscarriage or stillbirth. The bill builds on existing law requiring such services to be covered through delivery and the postpartum period.
For more ideas on how states can leverage payment to improve maternal health outcomes, see the recent SHVS issue brief Maternal Health Providers: Enhancing Health Equity Through Payment Parity.
Medical Debt
Illinois is relieving nearly $1 billion in medical debt. Governor JB Pritzker signed two pieces of legislation targeted at reducing the impact of medical debt on Illinoisans. HB5290, the medical debt forgiveness bill, dedicates approximately $10 million in state funding to purchase outstanding Illinois medical debt with the goal of erasing nearly $1 billion of medical debt in collections for Illinois residents. SB2933 makes medical debt ineligible to be included on a credit report, an action that is also being proposed at the federal level.
New Jersey implemented several policies to protect residents from medical debt. Governor Phil Murphy signed the Louisa Carman Medical Debt Relief Act which will help state residents avoid falling into medical debt and protect individuals from predatory medical debt collectors. The new law prohibits: credit reporting of medical debt to consumer reporting agencies going forward and all debt less than $500 at any date before the passage of the bill; creditors from charging interest rates of more than 3% annually; garnishing of wages for individuals with incomes up to 600% FPL; placing a lien on an individual’s primary residence; collections actions for 120 days after the first bill is sent. The law also requires a reasonable payment plan to be offered to individuals with medical debt.
North Carolina received CMS approval for a medical debt relief incentive program. Governor Roy Cooper and the North Carolina Department of Health and Human Services (NCDHHS) announced new actions to lessen the burden of medical debt for approximately two million low-income North Carolinians. NCDHHS received CMS approval for a set of conditions hospitals must meet to be eligible to receive a higher level of Medicaid reimbursement under the Healthcare Access and Stabilization Program, including relieving up to $4 billion in existing medical debt and establishing policies to prevent the accumulation of medical debt such as financial assistance policies and presumptive eligibility screening.
Vermont implemented financial assistance policies to protect against medical debt. A 2022 law, Act 119, went into effect on July 1, implementing a minimum floor for Vermont hospitals providing charity care to protect consumers from medical debt. Under the new requirements, Vermont residents with incomes up to 250% FPL will have access to free medical care at Vermont hospitals; residents with incomes up to 400% FPL will receive a discount of at least 40% on hospital bills or out-of-pocket costs if they are insured; and residents with incomes up to 600% FPL can be charged no more than 20% of their household income in medical bills. The law also bars hospitals from selling medical debt.
Virginia is prohibiting the reporting of medical debt to consumer reporting agencies. Effective July 1, Virginia began prohibiting certain medical care facilities, certain healthcare professionals, and emergency medical services agencies from reporting any portion of a medical debt, defined in the bill, to a consumer reporting agency.
For more information on state efforts to prohibit medical debt reporting and eliminate existing debt, see the SHVS expert perspective Mapping State Efforts to Address Medical Debt and a recent Health Affairs Forefront article which examines the burgeoning trend of state efforts to cancel medical debt for just pennies on the dollar.
Mental and Behavioral Health
Montana is investing in behavioral health services for American Indian communities. Governor Greg Gianforte announced an investment of up to $6.5 million in one-time grants to Tribal nations and Urban Indian Health Organizations to support and improve behavioral health services provided in American Indian communities. The funding can be used to improve, repair, or expand existing behavioral health facilities, support mobile crisis response teams, and cover transportation expenses to facilities that serve individuals with behavioral health needs in a culturally relevant manner.
Washington is leveraging patient stories to improve the behavioral health crisis system. The Washington Health Care Authority announced the launch of the Crisis Response Improvement Strategy (CRIS) Lived Experience Stories Project. This project will elevate stories of people across the state who have accessed behavioral health crisis services for themselves or someone else. The lessons learned from these stories will be integrated into recommendations for improving Washington’s behavioral health crisis system. A $25 gift card will be offered for the first 200 stories received.
Services for Children and Youth
North Carolina is investing in family-based behavioral health services for children with complex needs. The North Carolina Department of Health and Human Services announced an $11 million investment in treatment services designed to keep children who have complex behavioral health needs in homes and communities. The department is partnering with Rapid Resources for Families to expand access to family-based therapeutic programs, enabling children to receive trauma-informed treatment in a home-based setting.
New Mexico is providing continuous enrollment for children. New Mexico reinstated Medicaid coverage for approximately 21,000 children. Approximately 3,700 children in this group are between the ages zero to six and will now have continuous Medicaid enrollment up to the month they turn age six. Children ages 6 to 19 will be reinstated for a minimum of 12 months unless they have already turned 19 at reinstatement. SHVS recently published a toolkit to support states interested in, actively pursuing, or implementing section 1115 demonstrations to provide continuous enrollment (CE) to Medicaid and CHIP populations, with a focus on multi-year CE for young children.
New York is seeking to reduce suicide risk among youth. Governor Kathy Hochul announced five conditional awards totaling $15 million over five years to help community-based service providers develop innovative programs that will help reduce suicide risk among youth from under-resourced communities. Administered by the Office of Mental Health, the funding through the Connecting Youth to Mental Health Supports program will help develop programs and suicide prevention strategies for minoritized populations, including those in rural areas.
Waiver and State Plan Amendments, Requests and Approvals
Illinois, Kentucky, Oregon, Utah and Vermont will provide pre-release services to justice-involved individuals. CMS approved Medicaid reentry section 1115 demonstration requests for five states to provide Medicaid and CHIP coverage up to 90 days before an eligible person’s expected release from incarceration. This includes coverage of substance-use disorder treatment before an enrollee is released from jail, prison, or a youth correctional facility. Additionally, states will be able to help connect the person to community-based Medicaid and CHIP providers up to 90 days prior to their release to ensure they can continue their treatment after they return to the community.
New Hampshire received approval to provide certain pre-release services to justice-involved individuals. CMS also approved a five-year extension of New Hampshire’s section 1115 demonstration, “Substance Use Disorder, Serious Mental Illness, and Serious Emotional Disturbance, Treatment Recovery and Access.” Under the extension New Hampshire received new authority to provide certain pre-release services to eligible incarcerated individuals for up to 45 days immediately prior to the individual’s expected date of release.
New Mexico will provide health-related social needs services and pre-release services for eligible individuals. CMS approved a five-year extension of New Mexico’s section 1115 demonstration, which has been renamed “New Mexico Turquoise Care.” Under the extension the state received new authority to provide: (1) health-related social needs services to eligible individuals, and (2) pre-release services for certain eligible incarcerated individuals for up to 90 days immediately prior to the individual’s expected date of release.
Utah seeks to address health-related social needs. Utah submitted a request to amend its “Medicaid Reform 1115 Demonstration” to provide health-related social services to additional qualifying Medicaid-eligible groups and change the age eligibility for fertility preservation treatment for Medicaid-eligible individuals diagnosed with cancer.
For more information on the opportunity for states to provide certain pre-release healthcare services to justice-involved populations, see the SHVS webinar, Section 1115 Demonstration Opportunity to Support Reentry for Justice-Involved Populations: CMS Guidance.