Stock Photo by Sean Locke

Yesterday, March 3rd, the Centers for Medicare and Medicaid Services (CMS) approved Michigan’s application for its 1115 demonstration waiver for some children and pregnant women in Flint. In its application, the state estimated 15,000 individuals would be eligible for this coverage.

As requested by the state, CMS approved coverage for children and pregnant women up to and including 400 percent of the federal poverty level if they were served by the Flint water system between April 2014 and a state-specified date, yet to be determined. In their waiver request, Michigan asked that the waiver be for an indefinite time period. However, waivers are typically granted for five-year periods and then states can reapply. As expected, the waiver is effective through February 28, 2021. The five-year approval from CMS allows the state to waive all premiums and cost-sharing for the children and pregnant women covered and ensures that the children will receive Early and Periodic Screening Diagnostic and Treatment services.

Michigan will add Targeted Case Management (TCM) services to this population through certain providers who have “the capacity to provide all core elements of TCM, including assessment and development of a plan of care, referral, and linking to services and monitoring of services and related follow-up activities.” Families will have a choice of case managers.

As a reminder, children with lead poisoning may have these symptoms:

  • Tiredness or loss of energy
  • Hyperactivity
  • Irritability or crankiness
  • Reduced attention span
  • Poor appetite
  • Weight loss
  • Trouble sleeping
  • Constipation
  • Aches or pains in stomach

The Michigan waiver request lists resources for young children such as Early On (Part C), Head Start, and Great Start (state funded preschool for 4-year-olds). These programs are on the ground, and we hope they will be ramped up with staff and training to meet the needs of these children. However, questions remain about services for school age children, preteens, and teens. Will the state train those who work with at-risk youth, so they understand lead poisoning and its impact? Will the state train juvenile court judges, probation officers, police, medical, and school personnel? We hope so.

This waiver is a good start for the children and pregnant women of Flint who will be eligible. We remain concerned about the children who will not be eligible, specifically immigrant children, both documented and undocumented. Michigan has not adopted the Legal Immigrant Children’s Health Improvement Act (ICHIA) option, and thus leaves those children and pregnant women ineligible for Medicaid or the Children’s Health Insurance Program for five years. Clearly no one in Flint, or in the rest of Michigan for that matter, should have to wait five years for Medicaid coverage. Michigan could take up this option statewide and receive almost 99 percent federal funding for those kids, as they do for the kids already covered. For children in Flint without documentation of immigration, Michigan should cover them with state-only funds.

Within 120 days of the approval of the waiver, the state of Michigan has to send in their evaluation design for the five-year demonstration. There is definitely more meat on the bones in the waiver approval then there was in the waiver application in terms of evaluation design, and we are glad to see it. This is indeed a chance to learn what services and delivery systems help lead exposed children. We hope the universities and researchers in Michigan will be built into the evaluation portion of the waiver.

Lastly, the waiver approval doesn’t allow for lead abatement procedures as the state requested, due to limits within the 1115 waiver authority. CMS did agree to continue talking with state staff about what could be done through Title XXI of the Social Security Act in terms of a targeted and time-limited health services option that would support certain activities that would “complement other state and local efforts to remove lead from the homes of Medicaid eligible children and pregnant women.”

Michigan has 30 days to express their written consent to the terms and conditions of the waiver. In the meantime, we assume CMS and state staff in Michigan will work through any issues and get to a place of agreement. We hope children and pregnant women in Flint can start enrolling in Medicaid before the end of this month.


Medicaid expansion approved for children exposed to Flint water: v/ @First_Focus #InvestInKids
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