States of Innovation: November 2024

In November, states were driving the action on affordability and efforts to address costs, including California, which expanded its cost-sharing reduction program for Marketplace enrollees, and New Mexico, which published a report on the state’s Health Care Affordability Fund. As states continue to expand coverage for non-citizen populations, Colorado prioritized continuity of coverage for undocumented individuals and Minnesota expanded its Basic Health Program to undocumented individuals for coverage beginning in 2025.

Throughout the month of November many states sought to expand access to care: Minnesota is providing grants to help adults stay in their homes as they age, New Mexico is investing in rural health access, and Oregon Medicaid enrollees may now qualify for housing-related benefits. States also focused on improving health equity: Colorado published coverage guides on gender-affirming care and HIV prevention and treatment, while the District of Columbia is offering free care for heart disease through its standardized plans sold on the Marketplace. In terms of Marketplace innovations, Minnesota launched standardized plans for the first time and Oregon announced a request for proposals for a State-Based Marketplace vendor as it begins the process of establishing its own exchange.

States also focused on maternal health, including Alabama which launched the Center for Disease Control and Prevention’s “Hear Her Campaign” to prevent pregnancy-related deaths. State efforts in November to address medical debt for low-income residents included Illinois relieving $72 million of debt to date, while Rhode Island announced a medical debt relief program with a $1 million appropriation. As states work to improve mental and behavioral health, California awarded $33 million in grants through the Veterans Health Initiative, Michigan requested proposals for substance-use disorder treatment and recovery transportation services, and North Carolina invested in primary care capacity to support behavioral health.

Additionally, several states took action in November to protect reproductive and women’s health, with voters approving ballot initiatives to protect abortion rights and expand access to reproductive healthcare in seven states: Arizona, Colorado, Maryland, Missouri, Montana, Nevada and New York.  Massachusetts passed legislation to ensure access to follow-up breast cancer screenings and exams and Michigan is providing free contraceptives across the state. State action to improve services for children and youth includes Delaware, which is expanding access to dental care for children in schools.

Lastly, states received approval from the Centers for Medicare & Medicaid Services (CMS) for waiver and state plan amendments and requests. Five states were approved to provide additional years of continuous enrollment for children beyond the minimum 12 months required by law: Colorado, Hawai’i, Minnesota, New York and Pennsylvania. Wisconsin received approval to provide substance-use disorder benefits and extend coverage for certain populations. Two states, Florida and Tennessee, submitted requests to CMS to amend Medicaid section 1115 waivers.

Affordability and Efforts to Address Cost

California is reducing out-of-pocket costs for Marketplace enrollees. Covered California, the state’s official health insurance Marketplace, announced with the start of open enrollment that the state’s cost-sharing reduction program has been bolstered for 2025, increasing the amount of state funds available to $165 million. All Californians with incomes above 200% of the federal poverty level are eligible for an Enhanced Silver 73 plan with no deductibles and reduced out-of-pocket costs.

New Mexico published an annual report on the state’s Health Care Affordability Fund. The New Mexico Health Care Authority published the Health Care Affordability Fund (HCAF) annual report to the state legislature. The report includes updates on the state’s Marketplace Affordability Program, the small business health insurance premium relief initiative, the uninsured program, and HCAF finances and administration.

Coverage for Non-Citizen Populations

Colorado is ensuring continuity of coverage for undocumented enrollees. Connect for Health Colorado, the state’s official health insurance Marketplace, announced that with the start of open enrollment, the OmniSalud program for undocumented Coloradans is prioritizing continuity of coverage. The program, funded with state dollars up to an enrollment cap, encouraged those who enrolled in 2024 coverage to claim their spot for 2025 coverage by November 22. New customers seeking financial assistance were able to start applying on November 25, 2024.

Minnesota expanded its Basic Health Program to all income-eligible populations, regardless of immigration status. The Minnesota Department of Human Services announced the expansion of MinnesotaCare eligibility to include undocumented individuals, with coverage beginning in January 2025. MinnesotaCare is the state’s Basic Health Program for residents up to 200% of the federal poverty level.

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.

Expanding Access to Care

California is making it easier to find culturally and linguistically appropriate care for American Indians and Alaska Natives. As part of Native American Heritage Month, the Department of Health Care Services (DHCS) updated the Indian Health Care Programs Service Locator Tool, which helps users find medical, dental, nutritional, and behavioral health services and Native American healthcare providers near them. The updated tool reflects DHCS’ commitment to improving quality outcomes, reducing health disparities, and transforming the healthcare delivery system to ensure American Indians and Alaska Natives receive culturally and linguistically appropriate care.

Minnesota is providing grants to help aging Minnestoans stay in their homes. Governor Tim Walz announced over $6 million in state grants to keep Minnesotans in their homes as they age. The Live Well at Home grants will support more than 30 organizations and fund services such as retrofitting residences to make them age-friendly and provide support for caregivers.

New Mexico is investing in rural health access. Governor Michelle Lujan Grisham announced that four rural healthcare organizations will receive a combined $5.4 million from the Rural Health Care Delivery Fund. This is the first allocation from the $46 million fund championed by the governor and legislature during the 2024 legislative session. The initiative aims to tackle the unique challenges rural health providers face, including geographic isolation and financial barriers. The initial funding will support a range of vital services, including maternal healthcare, behavioral health programs, and primary care expansion.

New York announced a partnership with community-based home care providers. Governor Kathy Hochul announced 24 community-based home care providers will join the statewide partnership to strengthen New York’s Consumer Directed Personal Assistance Program, which provides home care services to New Yorkers. The partners collectively operate nearly 100 offices with service to all 62 counties throughout the state and have experience providing home care to New Yorkers who speak dozens of different languages. These partners have specialized home care experience, including focuses on seniors and children with intellectual, physical and developmental disabilities.

Oregon is expanding access to housing as a health-related social need. Oregon Health Plan members with specific health conditions may now qualify for new benefits to maintain their current housing and access other housing services. The housing benefits include: rent assistance for up to six months; utility set-up and payments for up to six months; home modifications and upgrades for health or safety reasons (e.g., grab bars, ramp installation, pest control); and rental navigation services. In October, the Oregon Health Authority and coordinated care organizations awarded a combined $37 million to community organizations across the state to help support the delivery of health-related social needs benefits to eligible Medicaid members. 

Pennsylvania published a report on network adequacy. The Pennsylvania Insurance Department released a network adequacy report which reflects the results of a study of the state’s Marketplace plans regarding provider directory inaccuracies and consumers’ ability to secure a timely appointment with both behavioral health and physical health providers.

Health Equity

Colorado published coverage guides on the availability of gender-affirming care and HIV prevention and treatment. The Colorado Division of Insurance, part of the Department of Regulatory Agencies, has prepared a guide on insurance coverage of gender-affirming care medical services for individual and small group health insurance plans, and a guide on insurance coverage of prescription medications to prevent and treat HIV to help Coloradans in choosing a health insurance plan for the coming year.

The District of Columbia is providing Marketplace enrollees free care for heart disease. Mayor Muriel Bowser announced that with the start of open enrollment, Essential Plans on DC Health Link, the District’s official health insurance Marketplace, will offer free care for heart disease. The leading cause of death in the District is heart disease, with the rate of Black residents who die from heart disease two and a half times higher than that of White residents. These standardized plans will charge no copays, deductibles, or coinsurance for residents seeking treatment for cardiovascular and cerebrovascular disease, including doctor visits, and medications. Additionally, these plans will continue to offer free type 2 diabetes care, including free insulin, removing financial barriers to doctor visits and medications.

Marketplace Innovations

Minnesota launched standardized plans in time for open enrollment. MNsure, the state’s official health insurance Marketplace, announced that with the start of open enrollment, Easy Compare plans will be offered for the first time. Easy Compare plans are standardized plans, making it easier for consumers to evaluate plan options.

Oregon is seeking a vendor to create a State-Based Marketplace. The Oregon Health Insurance Marketplace announced a new request for proposals for a State-Based Marketplace (SBM) vendor. Senate Bill 972 (2023) requires the Oregon Health Authority (OHA) to transition the Marketplace using the federal platform to a SBM in time for open enrollment for plan year 2027. Specifically, OHA is required to procure and administer both an information technology platform and call center, to replace the federal platform and call center, and provide electronic access to the health insurance exchange by November 1, 2026. Proposals must be submitted by December 30, 2024.

Maternal Health

Alabama is launching the Centers for Disease Control and Prevention (CDC) Hear Her Campaign. The Alabama Department of Public Health Maternal Mortality Review Program announced it will launch the CDC’s Hear Her Campaign. The Hear Her Campaign supports efforts to prevent pregnancy-related deaths by sharing resources for people who are pregnant or postpartum, their partners, family, and friends, and the healthcare professionals who interact with them.

Medical Debt

Illinois announced more than $72 million in medical debt has been relieved. Governor JB Pritzker announced the state’s medical debt relief pilot program has relieved more than $72 million worth of medical debt for 52,745 residents. This debt abolishment is the first effort as part of the state’s commitment to erase approximately $1 billion in medical debt. 

Rhode Island is leveraging $1 million for medical debt forgiveness. General Treasurer James A. Diossa announced a partnership with Undue Medical Debt, creating a medical debt relief program funded with $1 million previously appropriated in the state’s fiscal year 2025 budget. To be eligible, an individual must be a Rhode Island resident who incurred debt in order to obtain necessary medical treatment and has an estimated income equal to 400% or less of the federal poverty line or possess medical debt that is more than 5% of their estimated income.

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. SHVS also published a state spotlight on North Carolina’s comprehensive medical debt relief and reform incentive program.

Mental and Behavioral Health

California is supporting community-based organizations to provide mental health treatment for veterans. The California Department of Veteran Affairs has awarded $33.4 million in grants to community organizations in seven counties through the California Veterans Health Initiative, Mental Health Support Grant Program. The funding will enable community-based organizations to expand access to outpatient mental health treatment options for California’s veterans and their families.

Michigan is increasing the availability of transportation services for individuals with substance-use disorder (SUD). The Michigan Department of Health and Human Services (MDHHS) is seeking proposals for substance-use disorder treatment and recovery transportation services, aimed to reduce health disparities. A total of $1.2 million is available, with a maximum award of $200,000 per grantee. Grants are intended to encourage treatment and recovery service access and retention by serving under-resourced communities  in need of services and support. MDHHS anticipates issuing up to six awards. Funding is being made available through the Michigan Opioid Healing and Recovery Fund.

North Carolina is investing in primary care capacity to support behavioral health. The North Carolina Department of Health and Human Services announced $5 million to help providers implement the Collaborative Care Model in primary care offices across the state. Through the Collaborative Care Model, primary care providers work with an integrated behavioral health case manager and a psychiatric consultant to monitor and treat patients for mild to moderate behavioral health conditions. Collaborative Care is covered by NC Medicaid, Medicare and most commercial insurance plans in North Carolina.

Reproductive and Women’s Health

Arizona, Colorado, Florida, Maryland, Missouri, Montana, Nebraska, Nevada, New York and South Dakota approved ballot initiatives to protect abortion rights. In November, seven states approved ballot initiatives to protect abortion rights and expand access to reproductive healthcare: Arizona, Colorado, Maryland, Missouri, Montana, Nevada and New York.

Massachusetts is requiring coverage of follow-up breast cancer screenings and exams. Governor Maura Healey signed legislation to ensure that patients have access to follow-up breast cancer screenings and exams, while also preventing any increase in patient cost-sharing by 2026. Starting in 2026, the legislation will require insurers to cover diagnostic exams for breast cancer, digital breast tomosynthesis screening, and medically necessary and appropriate screening with breast MRIs and ultrasounds. It will also prevent any increase in patient cost-sharing, thus removing cost barriers for patients who need more rigorous screenings due to dense breast tissue or abnormalities seen in their initial preventive screening mammograms.

Michigan is providing free contraception across the state, regardless of insurance. Governor Gretchen Whitmer announced more than 300 locations across the state now have free contraception resources available through the Take Control of Your Birth Control program. The resources include over-the-counter oral birth control pills, emergency contraception, condoms and family planning educational resources. Participating locations include community partners, local health departments, MDHHS offices, and federally qualified health centers in every county of the state.

Services for Children and Youth

Delaware is expanding access to dental care for children in schools. The Bureau of Oral Health and Dental Services (BOHDS) launched the Kindergarten Oral Health Screening Program. In partnership with the Delaware Department of Education and school nurses, BOHDS facilitates all screenings and students receive a toothbrush, toothpaste, dental floss, dental resource guide, and the dental screening results to take home. The program was created with the passage of House Bill 83, which requires every public school and charter school to give a dental screening to students in kindergarten by the last day of the school year starting during the 2024-2025 school year.

Waiver and State Plan Amendments, Requests and Approvals

Colorado, Hawaii, Minnesota, New York and Pennsylvania were approved to provide additional years of continuous enrollment for children. CMS approved section 1115 demonstration amendments authorizing these five states to provide additional years of continuous enrollment (CE) for children beyond the minimum 12 months required by law, and will newly provide CE to individuals leaving incarceration in Colorado and Pennsylvania. As a reminder, SHVS published a toolkit to support states as they pursue section 1115 demonstrations to provide CE to Medicaid and CHIP populations, with a focus on multi-year CE for young children.

Florida is seeking approval to expand behavioral health and housing assistance. Florida submitted an amendment request for the Florida Managed Medical Assistance (MMA) section 1115(a) demonstration. The amendment proposes to expand the Behavioral Health and Supportive Housing Assistance Pilot to two additional regions; provide voluntary populations who enroll into the MMA program a choice of managed care plans and auto-assignment if no choice is made; transfer coverage of behavior analysis services from fee-for-service to managed care; and transfer coverage of non-emergency dental services provided in an ambulatory surgical center or hospital from MMA plans to dental managed care plans.

Tennessee is seeking approval to expand coverage for individuals with serious mental illness. Tennessee requested to amend their Medicaid section 1115 demonstration entitled “TennCare III.” The proposed amendment would expand the scope of services provided under the demonstration to include services for individuals with serious mental illness (SMI) or serious emotional disturbance who are receiving treatment in an Institution for Mental Diseases (IMD); support the implementation of a new quality improvement program for hospitals; and improve the efficiency and transparency of home and community-based services.

Wisconsin received approval to provide substance-use disorder benefits and extend coverage for certain populations. CMS approved a five-year extension of Wisconsin’s section 1115 demonstration, “Wisconsin BadgerCare Reform.” Wisconsin received renewed authority to (1) provide substance-use disorder benefits to cover short-term residential services in facilities that qualify as institutions for mental diseases; (2) provide coverage to out-of-state former foster care youth up to 26 years of age, who were enrolled in Medicaid in another state and turned 18 on or before December 31, 2022; and (3) extend coverage to non-pregnant, non-disabled, non-elderly childless adults with incomes of up to 100% of the federal poverty level.