Medicaid Expansions

This brief lays out the major factors that states have considered in estimating the cost of a potential Medicaid expansion, provides examples of state fiscal impact analyses, and highlights the tools created through the State Health Reform Assistance Network that additional states can use to inform their fiscal analyses as they consider the Medicaid expansion decision.

This brief examines the role of Medicaid in providing health coverage to the 9.6 million Medicare beneficiaries who are also eligible for Medicaid. The brief explains the role Medicaid plays in providing supplemental coverage to fill in the gaps in Medicare’s coverage for these dual-eligible beneficiaries. It explains how Medicare beneficiaries become eligible for Medicaid, provides national and state-by-state data on enrollment, and examines national and state-specific data on Medicaid spending for dual-eligible beneficiaries by service and eligibility group.

The ACA requires that Medicaid cover children with incomes up to 133 percent of the federal poverty level (FPL) as of January 2014. Today, there are “stairstep” eligibility rules for children through which states must cover children under the age of six in families with income of at least 133 percent of the FPL in Medicaid while older children and teens with incomes above 100 percent of the FPL may be covered in separate state Children’s Health Insurance Programs (CHIP) or Medicaid at state option. While many states already cover children in Medicaid with income up to 133 percent FPL, due to the change in law, 21 states needed to transition some children from CHIP to Medicaid. This brief examines how the transition of children from CHIP to Medicaid will affect children and families as well as states. The brief also looks to New York and Colorado for lessons learned from the early transition of coverage.  

Arkansas and Iowa recently released for public comment draft demonstration waiver applications proposing to implement the ACA’s Medicaid expansion by using Medicaid funds as premium assistance to purchase coverage for some or all newly eligible Medicaid beneficiaries in Marketplace (formerly called Exchange) Qualified Health Plans (QHPs). Arkansas and Iowa seek demonstration waiver authority primarily because they propose to make premium assistance enrollment mandatory for affected beneficiaries. Iowa also proposes to waive its obligation to provide wrap-around benefits. This fact sheet compares the two proposals. 

The success of integrated care initiatives for Medicare-Medicaid enrollees will depend in large part on the skills and knowledge of state Medicaid staff. Knowledge of Medicare policy, managed care oversight, data analysis and reporting, and communication strategies will be critical to program implementation. This technical assistance brief examines key areas where states will need to build their internal capacity as they pursue integrated care programs for Medicare-Medicaid enrollees. Focus areas include: basic organizational capacity; contract development; data analysis and information systems; stakeholder communication; rate setting; and quality measurement.