CMS Approves Indiana's Waiver Plan As Alternative to ACA Medicaid Expansion

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By Nora Macaluso

Jan. 27 — The Centers for Medicare & Medicaid Services Jan. 27 approved Indiana's request to expand its Healthy Indiana Plan offering health insurance to low-income Hoosiers as an alternative to traditional Medicaid expansion.

Coverage will begin Feb. 1, as the state ends traditional Medicaid in favor of the new plan, which includes health savings accounts and copayments, including copayments for some emergency-room visits as part of a study to determine whether copays are effective in encouraging appropriate care without harming beneficiary health, according to the CMS.

The plan, which currently covers about 45,000 people, will be expanded to include an additional 350,000 uninsured state residents, Gov. Mike Pence (R) said in a Jan. 27 statement. It provides tiers of coverage: a basic plan with limited benefits and incentives for preventive care; a more extensive plan that requires participants to contribute to health savings accounts (HSAs); and an option for eligible individuals to choose employer-sponsored plans and use their HSAs for cost sharing, premiums or deductibles.

The plan was submitted to the CMS July 1, 2014.

The CMS said it didn't approve some of the plan's original features, including a requirement that beneficiaries seek work. Indiana will offer job training and job-search assistance through a state-funded program that will be administered separately. “While states may promote employment through state programs operated outside of the demonstration, this is not permitted under the Medicaid program,” the federal agency said in a Jan. 27 statement.

The CMS said that Indiana will become the 28th state, plus the District of Columbia, to expand Medicaid under the Affordable Care Act. 

In the statement, Health and Human Services Secretary Sylvia Burwell said, “The Administration will continue to work with governors interested in expanding Medicaid to devise approaches that work for their states while keeping faith with the law’s goals and consumer protections.”

Penalties for Failing to Maintain HSAs

The CMS also prohibited capped enrollment, premium payments as a condition of eligibility for people with incomes below the federal poverty level and premium payments of more than 2 percent of income.

However, those with incomes above 100 percent of the federal poverty level who are not “medically frail” may be locked out of the program for six months if they fail to contribute to their health savings accounts, according to terms of CMS’s approval. Contributions to the accounts, known as “POWER” accounts, range from $3 to $25 per month, according to the state.

The CMS noted that the expansion is paid for with 100 percent federal funds through 2016. Federal funding rates gradually decline beginning in 2017, “but never fall below 90 percent of costs.”

According to a document describing the financing of the Medicaid plan, Indiana and the Indiana Hospital Association “have reached a mutually beneficial agreement” regarding the use of the hospital assessment fee, or HAF, to fund an expansion. “Hospitals through the HAF would begin making contributions in 2017, when the federal government requires a State contribution for health related costs for HIP expansion.”

The Healthy Indiana Plan demonstration project had been extended three times while state and CMS officials discussed terms of the waiver that would allow it to function as an alternative to Medicaid for purposes of expansion under the ACA.

To contact the reporter on this story: Nora Macaluso in Lansing, Mich., at

To contact the editor responsible for this story: Nancy Simmons at


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