The Disabled Workforce

Glossary of Medicaid, Medicare, VA, Health & Other Related Program Terms:

209(b) states---CT, HI, IL, IN, MN, MO, NH, ND, OH, OK and VA; retain some old, minor, slightly stricter-than-SSI aged and disabled Medicaid eligibility rules due to long-forgotten, no-longer-justified state policy decisions made over 30 years ago; hence, SSI does not confer automatic Medicaid eligibility and the aged and\ disabled must also apply separately and duplicatively for Medicaid at welfare offices, causing unnecessary, expensive welfare workloads; 209(b) states that don’t otherwise have spend downs (IN, MO, OH and OK) must in exchange allow the aged and disabled to spend down; named for Section 209(b) of Public Law 92-603.

1634 states---AL, AZ, DC, DE, FL, GA, KY, LA, MA, MD, ME, MI, MS, MT, NJ, NM, NY, NC, PA, RI, SC, SD, TN, TX, VT, WA, WV, WI & WY are “1634 states’ that give Medicaid automatically to all SSI recipients and, except for group home SSPs, they also arrange for SSA to pay any SSPs automatically, and on top of, the basic federal SSI payment; named for Section 1634 of the Social Security Act, which authorized this procedure.

Acceleration---the process by which an individual or group life insurance policy itself pays a portion (usually up to 50% of the face benefit amount with the rest staying in place for payment to beneficiaries) of the death benefit early to an insured person who can document s/he is terminally ill or medically needs nursing home or home nursing care; the early payout, unlike with viatication, is not reduced actuarially or for profit, except for a small transaction fee; payments are tax-free but—unless used for nursing care--countable by SSI, welfare, Medicaid & VA pension & medical programs; paid in lump sums, except for monthly pay-outs for nursing care.

ADLs---Activities of Daily Living; patients must suffer some deficits in (inability to perform) common ADLs (speaking, hearing, thinking, modulating emotions, sitting, eating, bathing, dressing, walking, toileting, etc.) to qualify medically for SNF, ICF, HCB, home health, personal attendant, supervised group home SSPs & VA A&A benefits. But SNF, ICF, HCB & home health patients must also need professional-level medical services.

ADAPs---AIDS Drug Assistance Programs; federally-funded, state-run programs to provide drugs to uninsured or under-insured HIV+ persons with incomes & assets below state-set levels; most states add their own funds.

Aid & Attendance---an extra $589.83 monthly (2006) added to the VA pension for disabled & over-age-65 wartime veterans with significant ADL deficits; their surviving spouses get A &A pension add-ons of $353.83.

Allowable charges or reasonable charges or costs---the amount which Medicare, each Medicaid & CHIP program & each private insurance plan will pay, under its own individual rules, for a given medical service or item; but any deductible, co-pay or coinsurance due from the patient is subtracted from this figure.

Asset—or “resources” level; the maximum amount of liquid assets allowed to be eligible for needs-based programs; called “net worth” levels by the VA; virtually all programs also permit a lived-in home of any value, one vehicle, household goods, small burial funds or plots & life insurance with low cash surrender value.

Auxiliary Social Security benefits---smaller benefit checks given to each dependent or surviving minor child (and sometimes their other parent too) of disabled, retired or deceased Social Security-covered workers.

BCCPTA---the Breast & Cervical Cancer Prevention & Treatment Act offers states the higher CHIP matching rate to give full Medicaid (not just cancer care), but with no income or asset test, to uninsured women under 65 who screen positive for breast or cervical cancer or precursors (e.g., HPV, human papilloma virus; PID, pelvic inflammatory disease) at free, federally-funded local cancer screening centers; DC & all states do so.

Buy-in---since 1965, the process by which states pay Medicare Part B--and, where appropriate, Part A-- premiums for their Medicare-eligible Medicaid and MSP patients; but also used since 1997-99 to describe the option for states to give Medicaid, paid for via low sliding scale premiums (“buy-ins”) charged to working disabled, “ex-disabled” & even “pre-disabled” persons with earnings under extra-high income eligibility levels.

CAPs---Combined Application Programs, sponsored by SSA & the Food & Nutrition Service, give food stamps automatically & simultaneously to SSI recipients living independently, without need to apply at welfare offices.

Capitation---the process by which Medicare, Medicaid or other health coverages purchase a set package of health services that may be needed from HMOs &other managed care organizations, for a per-patient price.

Caretetaker—under the old AFDC welfare program---and AFDC-based Medicaid too--this was almost always the single welfare mother, since a second parent couldn’t be covered unless he was involuntarily unemployed after a long work history or “incapacitated” (disabled under state rules more liberal than SSA’s). This was called the “man-in-the-house” rule. But states also let any other relative raising children & pooling income with them be caretakers in loco parentis & thus recipients of AFDC & Medicaid, and this is still true. With welfare reform in 1996, TANF replaced AFDC & states could now give TANF & Medicaid to two parent families. Few did so for TANF (they kept “man-in-the-house”/unemployment/incapacity limits) but almost all now give Medicaid to two parent families: A little-known, big liberalization buried in a conservative welfare reform law.

Caring Program for Children—also known by other, similar names; subsidized, cheap health insurance for children (and sometimes parents too), once-–and perhaps still--offered by some (but not all) Blue Cross plans.

Categorically needy (CN) —in Medicaid eligibility, these were originally those whom states had to cover because they received, or were eligible for, AFDC (now called TANF), SSI or, at state option, SSPs. But from the very beginning and increasingly over the years, this principle quickly eroded, and states also had to cover, or could choose to cover, as CN, other persons who generally meet CN-type income/asset levels but who don’t or can’t get checks (e.g., Ribicoff children under AFDC/TANF income levels who can’t actually get TANF because they’re not living with a parent; aged & disabled who can’t actually get SSI because they’re in a medical facility; those too proud to take the SSI “welfare” check, but who still want Medicaid). Now (with some minor exceptions), states can and do set their CN income & asset levels as high as they want, category by category, independent of, and higher than, TANF, SSI or SSP levels: pregnant women & infants; children 1 to 6; children 6 to 18; families (now usually both parents, or relative caretakers in loco parentis, plus children); aged; blind; disabled; TB-infected persons; uninsured women under 65 screened positive for breast or cervical cancer or precursor conditions; the working disabled, “ex-disabled” and/or “pre-disabled”; and other categories.

CHAMPVA—premium-free health insurance for dependents & survivors of 100% disabled service-connected veterans & those dying on active duty; recently extended for secondary-to-Medicare coverage of those over 65.

CHIP (or SCHIP)—State Child Health Insurance Program; federally-matched, state-run programs offering free or very-low-premium health insurance to children of the working poor with family incomes over state Medicaid levels; states’ CHIP matching rates are roughly almost 15% higher than their Medicaid matching rates; waivers can also cover parents & other in loco parentis related caretakers (e.g., NJ, RI & WI); unlike Medicaid, CHIP has no spend down, but a few states let over-income families buy into it with bigger premiums.

CMS---the Centers for Medicare & Medicaid, formerly called the Health Care Financing Administration, or HCFA, the federal agency responsible for running Medicare, overseeing state Medicaid and CHIP programs and administering other health programs.

COBRA---Consolidated Omnibus Budget Reconciliation Act of 1986, which requires most employers to permit former employees & dependents; their former spouses; and their majority-aged children to purchase continued coverage in the employer health plan at their own expense for 18 months (plus 11 months more if one timely reports an SSA disability application) & 36 months for divorced or widowed spouses or majority-aged children

.

Coinsurance---is the percentage of a given medical care service’s or item’s cost that the patient, rather than his health coverage, must pay; a co-payment is a fixed dollar amount portion of the cost that the patient must pay.

Crowd out---the concern of policymakers, and consequently their attempts to counter, the feared likelihood that parents with children who are income-eligible for CHIP would enroll them in CHIP at public expense, rather than add them as dependents (usually at some premium cost to themselves) to their available job health plans.

DAC—a disabled adult child whose disability first onsetted before the age of majority & who gets SSDI based on the Social Security record of a dead, disabled or retired parent; benefits equal about 60% of the parent’s own.

Deductible--a fixed annual amount of medical care which a patient must pay before his health coverage begins.

DIC—Disability Indemnity Compensation is paid to surviving spouses & children of service-connected disabled veterans; dependents & survivors of those rated 100% disabled also get CHAMPVA health insurance.

Disregard---an amount and/or percentage of gross, total income that’s not counted against a program’s eligibility income level; some programs have separate disregards for earned and unearned or general income.

Donut hole---yearly gap of non-coverage of drug costs, after $2250 up to $5100, for Part D patients with income over 150% FPL.

Dual eligibles—Medicare patients who are also eligible for full Medicaid coverage in their states, and not just MSP benefits.

EPSDT---Early & Periodic Screening, Diagnosis & Treatment, since 1969, must be offered & provided by state Medicaid programs for eligible children; states must provide services & items like dental care, eyeglasses, hearing aids, etc., without cost-sharing, even if they’re ordinarily not covered by the state Medicaid program.

Extra Help---enhanced Part D drug benefits, with no donut hole, for those with incomes under 150%; those under 135% face no premium or deductible & co-pays of $1, $2, $3 or $5; those from 135% to 150% have low premiums, a $50 yearly deductible & coinsurance of only 15%.

ETHA---Early Treatment for HIV Act, a bill that would offer states the higher CHIP matching rate to give Medicaid to HIV+ persons (even if not yet disabled) with incomes under extra-high eligibility levels.

Family Opportunity Act---a bill that would allow states to give Medicaid, using extra-high income eligibility levels & with sliding scale cost-sharing, to disabled children in middle-income families whose job health insurance doesn’t offer the rehabilitative, respite, equipment, home health & specialized care Medicaid does.

Fee-for-service---the process by which Medicare, Medicaid and other health coverages pay for their eligible patients’ care, bill-by-individual-bill, as submitted by doctors, hospitals & other medical providers.

Formulary---a list of drugs covered by a Part D plan, Medicaid, CHIP, a private insurance plan or an HMO.

General Assistance or Temporary Disability Assistance or Home Relief—welfare, and often medical assistance, offered by most liberal “blue” states---but few conservative “red” states--- to destitute, unemployed and disabled childless adults, often while awaiting the long SSA disability determination process.

Group homes---supervised, often-licensed sub-medical-level “assisted living”, congregate, domiciliary, “family”, “rest”, “room & board”, “adult foster”, “personal care”, “residential care” and “boarding” homes for frail aged or disabled persons, run by agencies or even private owners; their residents, in all but a few states, qualify for extra-high SSPs with which they pay their (enhanced) rents and that confer Medicaid eligibility.

HCB waivers—Home & Community-Based waivers expand on traditional, standard Medicaid services by offering intense home health services, group home care and/or case management, instead of nursing home placement, to targeted groups of the frail aged and disabled, often using extra-high income eligibility levels.

Health Insurance High Risk Pools—state-sponsored & subsidized (with general or premium taxes) health insurance for those with pre-existing conditions who can’t get Medicaid or affordable private coverage; run for states by insurance company contractors; yet even their state-subsidized rates are quite high (a few states do give discounts to those considered poor); most, but not all, deny full secondary coverage to Medicare patients.

HIFA waivers—state Medicaid waivers promoted by the Administration to cover more persons, often giving extra up-front federal funds, but usually at the cost of less benefits for new (and sometimes even original) Medicaid patients & possibly less future funding.

HMOs---health maintenance organizations deliver pre-defined health benefits (often including extra preventive care) for capitated rates at their own outpatient facilities, or via limited participating provider networks, and at selected hospitals, with patients paying co-pays that are often below fee-for-service coinsurance amounts.

Home health care—brief professional-care visits, ordered by a physician & given at patients’ homes, by RNs, LPNs and speech, occupational, physical, phlebotomy & other therapists which Medicare, Medicaid, the VA and some private insurance cover; often, brief supportive visits by home health aides, homemakers, etc. are covered but only when and after the underlying professional-level visits are found necessary and authorized.

HRSA---the federal Health Resources and Services Administration, which oversees & funds the Ryan White HIV care & ADAP programs; finances low income community health clinics; administers the Hill-Burton free hospital care & patient access rules; and runs other miscellaneous health programs.

ICFs—intermediate care facilities; lower-level medical long term facility care paid for by Medicaid and often used by mentally-challenged, developmentally disabled and other severely disabled patients.

IHS---Indian Health Service, a federal agency that offers free health care at IHS or tribal facilities to Native Americans living on or near reservations; and limited, outpatient care, with sliding scale fees, at urban clinics.

Life settlements---viatical transactions, sometimes (but not exclusively) based solely on old age (i.e. over 62).

LIHEAP---federally-funded, state-run Low Income Home Energy Assistance Program that pays part of the poor’s heating bills.

Matching rate---the percentage that the federal government pays to states for certain program expenses---most notably, Medicaid’s; the richest states get 50% and the poorest one gets about 80%, with many in-between depending on their per capita average incomes and economies; states only get matching for paying federally-allowable rates for federally-allowable medical costs of persons whom federal law requires or allows them to cover; states get higher matching for some expenses (100% for family planning & certain computerization costs) but all get only 50% for the personnel & administrative costs of their Medicaid & welfare bureaucracies.

MediCal---California’s name for its Medicaid program.

Medically needy (MN)---in Medicaid eligibility, these are federally-matchable persons “categorically-related” by Medicaid law: Aged, blind, disabled, parents & children, etc. who in principle have incomes and/or assets above TANF, SSI or SSP levels—and who, unlike the categorically needy, get to deduct their paid & incurred medical expenses from their gross, originally “excess” income to make it low enough (to become poor enough) to be eligible. States choosing to cover the MN generally use 1, 3 or 6 month MN spend down eligibility budgeting periods. Originally, states opting to cover the MN had to set uniform family-sized MN income & asset levels for members of all the categories. While states generally continue this practice, CMS has since let them to vary their MN levels from category to category, especially to avoid inequities. It also let them cover only one or some MN categories (but not all), as Texas once did by covering MN families, but not other MN categories. At first, state MN levels couldn’t exceed 133% of whatever a state’s AFDC (now TANF) program paid to a family of the same size---but now states can, and sometimes do, set their MN levels as high as they want. Most notably, they can raise their MN levels for the aged & disabled from 133% of the TANF level up to the SSI/SSP level to avoid the prior unfair & incongruous result of requiring aged & disabled persons to spend down even past & below the SSI/SSP level to a lower MN level tied to 133% of TANF’s level.

Medicare and Medicaid---if you don’t know what they are, and the difference, you aren’t qualified to even be reading this paper.

MSP---Medicare Savings Programs’ (QMB, SLMB and QI) eligibility is determined by local welfare offices; they pay Medicare premiums for those with income under 135% FPL (even if they’re “too rich” for full Medicaid) and, for QMB eligibles under 100% FPL, deductibles & coinsurance too.

PAPs---Patient Assistance Programs; drug manufacturers’ charities that give free or discounted drugs to the needy under corporate income levels, often by effectively requiring drug salesmen’s access to their doctors.

Part A---of the Medicare law pays for hospital, limited nursing home, home health & hospice benefits; it is premium-free, except for disabled back at work over 99 months & those over 65 with insufficient work credits.

Part B---of the Medicare law pays doctor and outpatient medical bills; its premium is $88.50 monthly in 2006.

Part C---of the Medicare law that lets patients enroll in private HMOs, PPOs & other managed care plans (often with extra coverage & sometimes extra premiums) instead of traditional fee-for-service coverage.

Part D---of the Medicare law offers outpatient prescription drug coverage to Medicare patients, beginning January 1, 2006---through numerous private plans, each with different rules & average, “benchmark” premiums of about $32—but giving much more generous “Extra Help” benefits to those with incomes under 150% FPL.

Pension---in VA parlance, a welfare-type payment (in 2006, up to $881.58 monthly for single veterans) for disabled or over-65 veterans of VA-defined “wartime” periods, even if they didn’t serve in a war zone or their disability is not service-connected; our almost-constant wars since 1941 qualify most veterans as “wartime”.

Personal care/attendant services---physician-ordered, non-professional, home or even at-work personal aide services for those with ADL deficits paid for by many (but not all) Medicaid programs, up to state-set limits.

Pharmacy Plus waivers---waivers once promoted by CMS to allow states to give Medicaid drugs, but not other services, to the aged & disabled, with income over regular Medicaid levels but below 200% FPL; FL, IL, MD, SC, WI & 2 or 3 other states have/had them.

PLHIV—person living with HIV; s/he may or may not, have yet advanced to “full-blown” AIDS and may, or may not, yet meet SSA disability rules for getting SSDI or SSI; most PLVIVs are, in fact, “pre-disabled”.

PPOs—health coverage through “preferred provider” organizations; “loose”, watered-down HMOs with some fee-for-service features; patient cost-sharing is usually much higher for care from “out-of-network” providers.

Primary and secondary payers---which health coverage pays first, and which pays any remaining due balance second (or even third or fourth) under CMS & HRSA rules, supplemented by insurance industry standards; Medicare is primary to Medicaid and usually, but not always, to private insurance; Medicaid is secondary to almost everything else (except ADAP & the IHS); and industry rules decide among private payers.

PWA---person with AIDS; s/he often, but not always, meets SSA disability rules & is eligible for SSDI or SSI.

Ribicoff children—once widely-used term for children who get Medicaid other than through TANF (formerly

AFDC) or SSI, usually based on family income and, often, even where their parents don’t qualify for Medicaid.

Ryan White Program—funded by HRSA; offers health services (e.g. ADAP) to HIV+ people through states, localities & non-profits.

Senior settlements---viatical transactions, usually (but not exclusively) based solely on old age (i.e., over 62).

Service-connected---in VA parlance, an illness or injury first incurred while on active duty, for which a veteran gets an appropriate percentage (10 to 100%) of disability compensation & high priority for VA medical care.

SNFs---skilled nursing facilities offer medical-level nursing care 24/7 to those whose medical conditions & ADLs require such care; paid for by Medicaid, private funds & long term care insurance; called “extended care” by Medicare & private insurance, which only partially cover limited days & only after hospitalizations.

SPAPs---State Pharmacy Assistance Programs; 100% state-funded programs that pay for drugs for aged and, in some states, disabled persons who are slightly “too rich” for Medicaid; a few state SPAPs even get federal funds via Medicaid “Pharmacy Plus” waivers.

Spend down---the process by which those with countable incomes above state Medicaid spend down income levels (which are higher than TANF levels but often lower than SSI levels) must pay or incur medical bills equal to their excess to gain eligibility; called “share-of-cost” in CA; states use 1, 3 or 6 month eligibility time periods.

SSA---Social Security Administration; pays earned Social Security retirement (age 60 for the widowed; 62 for reduced old age benefits; 65-67 for full benefits); survivors (to children & spouses of deceased workers) [OASDI] and disability [SSDI] benefits (plus auxiliary benefits for children); SSI; and, in most states, SSPs.

SSBG—once known as “title XX”, the federal Social Services Block Grant, supplemented by most states, funds social services for poor families, children, the aged and the disabled (housekeepers, homemakers, child-raising training, budget counseling, respite care, case management, child and adult protective and abuse services, etc.)

SSI---Supplemental Security Income; federal welfare program for the poor aged & disabled that pays up to $603 monthly (2006) and, in almost all states, confers Medicaid eligibility.

State Supplementary Payments (SSPs) are extra state payments added to basic federal SSl by most liberal “blue” states---but few conservative “red” states. SSPs can be, and most commonly are, paid to those living independently. But states can and do offer, or not offer, them--or vary their amounts--by types of living arrangement. Most notably, all but the “reddest”, most conservative states pay an extra-high SSP to frail aged & disabled persons living in supervised, sub-medical-level group homes. SSPs can be paid for states (but at their expense) by SSA as add-ons to the basic federal SSI payment, and most states arrange for that. But others pay the SSP themselves through their welfare offices, thus requiring the aged & disabled to apply duplicatively & unnecessarily at two offices and needlessly adding to their own welfare workloads. Yet almost all states pay their special, extra-high SSPs for those in supervised group homes only through their own welfare offices so that their aged/disabled social services & adult protective staffs can better monitor placements & care.

State-only or General Medical Assistance—Medicaid-like care offered without federal aid by most liberal “blue” states---but few conservative “red” states—to those poor who don’t fit into federal Medicaid categories.

TANF---Temporary Assistance to Needy Families; federally-aided, state-run welfare; formerly Aid to Families with Dependent Children (AFDC); TANF recipients, both children & parents, get automatic Medicaid.

Ticket to Work---federal options letting states give Medicaid to the working disabled, “ex-disabled” & even “pre-disabled” using extra-high income eligibility levels; other program features offer clients continued Medicare, enhanced vocational rehabilitation and SSDI & SSI benefit protections.

Title I---of the Social Security Act created the pre-SSI (1935-1974) Old Age Assistance (OAA) and Aid to the Blind (AB) federally-matched, state-run welfare programs for persons over age 65 and blind persons over 16. Title I, rather than Title II (the actual “Social Security” part of the Act that history now celebrates) was--incongruously and surprisingly to present-day eyes--the part that 1935’s politicians, media and public almost exclusively focused on because of the intense need of Depression seniors and the blind for immediate income.

Title II---is the core “Social Security” part of the Act; it created the Old Age, Survivors and Disability (OASDI) Social Security programs, which are paid by SSA from taxed wage-earnings.

Title IV-A--is the welfare part of the Act; it created (1935) the federally-matched, state-run Aid to Families with Dependent Children (AFDC) welfare program (now Temporary Assistance to Needy Families, or TANF).

Title IV-D---the child support enforcement section of the Act, which helps fund state collection activities.

Title V---the maternal & child health section of the Act, which funds the Maternal & Child Health and Special Needs Children (formerly “Crippled Children’s”) block grants to states; and the Women’s, Infants’ & Children’s (WIC) program, which offers health screening, immunizations, counseling & referrals---plus vouchers for food purchases—to families with pregnant women or children under 5; most states add their own funding as well; these programs typically have state-set income eligibility levels of about 185/200% FPL.

Title XIV---of the Act created the pre-SSI (1949-1974) Aid to the Permanently and Totally Disabled (APTD) federally-matched, state-run welfare program for disabled adults.

Title XVI states---AK, ID, KS, NE, NV, OR & UT; they do accept SSI eligibility rules for aged & disabled Medicaid eligibility, but not automatically; they still make them apply separately & duplicatively for Medicaid at welfare offices---causing unnecessary, expensive welfare workloads---due to long-forgotten, no-longer-justified state policy decisions made over 30 years ago; and title XVI of the Act is, of course, the SSI law.

Title XVIII---the Medicare section of the Act; added in 1965.

Title XIX---the Medicaid section of the Act, also added in 1965.

Title XX—see SSBG.

Title XXI---the State Child Health Insurance Program (CHIP or SCHIP) section of the Act; it offers states federal matching funds at rates almost 15% above their Medicaid matching rates to give health insurance to Medicaid-ineligible children of the working poor, using income levels up to 200% FPL or even higher.

Transitional Medical Assistance---Medicaid eligibility extensions of 6 months (and, at state option, 6 or more additional months) given to parents in TANF welfare-to-work programs whose new earnings would otherwise make them (and often even their children) “too rich” for Medicaid.

Tricare—free health insurance (but with premiums for enhanced benefits) for dependents of active duty military & activated Reservists & National Guardsmen; career & disability military retirees; and retirees’ dependents & survivors. Military & health advocates support a Clinton-Graham Senate bill to extend it to un-activated Reservists, Guardsmen & their dependents, but with patients paying part of even basic premiums.

TrOOP---true out of pocket drug costs; in Part D, drug expenditures that can be counted & credited in calculations to reach the annual $2250 donut hole threshold & its $5100 ceiling, after which patients qualify for catastrophic drug coverage for the rest of that year with very low coinsurance; drug costs paid by Part D, Extra Help, a patient himself, his relatives, SPAPs (but not ADAPs or Medicaid) and some charities count for TrOOP.

Two year waiting period---a 1972 law extended Medicare to the disabled but only after 24 months on SSDI and to those experiencing permanent kidney failure, prolonged dialysis or kidney transplant after only a 3 month wait (they needn’t qualify for SSDI if they, a spouse or parent is Social Security-insured); and Congress recently made those with amyotrophic lateral sclerosis (ALS; Lou Gehrig’s Disease) immediately eligible.

Viatication---the sale of ownership of, or assignment of policy rights to, individual or group life insurance for an actuarially-reduced price below the face death benefit amount to a private investor by an insured person who can medically document s/he is terminally ill; requires nursing home or home nursing care; or is simply over age 62. Payments are tax-free, but, unless used for nursing care, are countable by SSI, welfare, Medicaid & VA pensions & medical programs; are made in lump sums, but nursing care payments are often disbursed monthly.

Waivers—are authorized by Section 1115 of the Social Security Act & similar provisions in CHIP’s & other programs’ laws; given by CMS, HHS & other administering agencies, they let state- or even federally-run programs depart from ordinary eligibility or benefit rules for temporary periods---ostensibly & nominally to test new, innovative policies but often also to expand eligibility, coverage or services or save on budget expenses.

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