While it may be true that you can't always get what you want, sometimes you can get pretty darn close. Just ask Indiana Republican Gov. Mike Pence. In May 2014, the potential GOP presidential candidate requested an ambitious Medicaid expansion waiver that would rely heavily on conservative-friendly ideals, such as dedicated health accounts, personal responsibility and a strict plan for member noncompliance. And to the surprise of some the federal government gave Gov. Pence the lion's share of what he was asking for.

The move allows Indiana to become yet another Republican-led state to expand Medicaid, and though Indiana's waiver may be complicated for members to navigate (one of the criticisms coming from advocates), it could open the door for other conservative-leaning states looking to reshape the program.

There are two plans: Healthy Indiana Plus and Basic. Under the Plus offering, required for beneficiaries earning between 100 percent and 138 percent of the federal poverty level, members are required to make a monthly contribution to a dedicated health account. Depending on their income, the monthly contribution will likely be between $3 and $25. Healthy

Indiana Plus also includes an enhanced benefit package with vision and dental; since dental benefits are not offered to adults in many traditional Medicaid benefit packages, the Plus option is intended as a member enticement to offset the financial requirement. Beneficiaries who are unable to make their contributions (with a 60-day grace period) will lose access to the program for a six-month lock-out period a provision surprisingly granted by the federal government. While many advocates have called that penalty too harsh, rest assured this measure has not gone unnoticed by other Republican-leaning states still debating Medicaid expansion, such as Montana, Tennessee, Utah, and Wyoming.
Indiana's Basic plan, designed for those with incomes below the poverty level, does not require financial contributions to a health account. While HIP Basic is designed to provide essential health benefits, it does not cover vision or dental care; it also provides a less-generous pharmacy benefit and requires copays for services. It is Indiana's way of saying it pays to contribute to the health account.

And, in another surprise, the Obama administration granted Indiana's request to charge beneficiaries a $25 copay for the second, and subsequent, non-emergent use of the ER. The first visit carries a traditional $8 copay. Advocates have already begun questioning the merits of this approach, though the Centers for Medicare & Medicaid Services put a two-year limit on the fee, after which it will be re-evaluated.  Regardless, with these moves, the Obama administration has shown it is willing to make concessions in order to nudge holdout states on the fence into the expanded column.

Indiana's somewhat generous approval follows a pattern of states pushing the envelope in their proposals to the federal government. Arkansas, Iowa, Michigan and Pennsylvania have expanded Medicaid in their own way under the Affordable Care Act through waivers, each taking various approaches with different wrinkles thrown in be it a limitation on transportation benefits, new cost-sharing requirements for the expansion population or wellness incentives.  Expect some, or all, of these measures to be included in requests from potential waiver states such as Montana, Tennessee, Utah, and Wyoming if they can move past their own internal political hurdles, that is.

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