Medicaid Expansions

This brief outlines key program design features of alternative Medicaid expansion models. It describes the premium assistance models Arkansas, Iowa, and Pennsylvania developed to use Medicaid funds to purchase private health insurance, as well as Michigan’s proposal to expand Medicaid using a health savings account model. Key themes emerging from these non-traditional proposals include: (1) a preference for solutions relying more on the private insurance market than on traditional Medicaid; and (2) an emphasis on higher enrollee cost-sharing, personal responsibility, and healthy behaviors.

This letter provides guidance to states on how the long-term services and supports-related rules apply to individuals who are eligible for Medicaid under Modified Adjusted Gross Income (MAGI) eligibility rules, and receive coverage for long-term services and supports (LTSS). Some people who need LTSS may qualify for Medicaid under MAGI rules. This guidance is intended to address states’ questions regarding whether the various Medicaid LTSS rules, including the estate recovery rules, will apply to MAGI individuals who are eligible for LTSS coverage.

Medicaid comprises a significant portion of state budgets and is expected to grow as states expand coverage under the Affordable Care Act (ACA). Given this projected growth, understanding Medicaid’s financing structure, its burden on taxpayers, and any unintended consequences of the federal matching grant is particularly important. The matching grant, in place since the enactment of Medicaid, uses the Federal Medical Assistance Percentage (FMAP) to reimburse states for the federal share of states’ Medicaid expenditures. This study snapshot presents an overview of the estimated federal and state Medicaid tax burdens per family.

Prior to the ACA, one key reason a number of states used Section 1115 waiver authority was to expand Medicaid coverage to low-income adults who could not otherwise be covered under federal rules. The ACA’s Medicaid expansion to nearly all low-income adults at or below 138% FPL, and the significant federal funding provided to states for this expansion, fundamentally alters the role of Section 1115 waivers in expanding coverage to adults. Through guidance and recent waiver approvals in three states, CMS has identified some of the parameters related to the use of waivers to expand coverage to adults in light of the ACA’s Medicaid expansion. This brief provides an overview of the potential role of Section 1115 waivers to expand coverage since the enactment of the ACA and key themes in recently approved and proposed coverage expansion waivers.

The ACA allows hospitals to use preliminary information to enroll people who appear eligible for Medicaid into coverage on a temporary basis. The goal of this “presumptive eligibility” (PE) option for hospitals is to quickly and efficiently enroll eligible people into Medicaid while insuring immediate health care costs are covered. While presumptive eligibility is not a new concept in Medicaid, the ACA for the first time gives hospitals – rather than states – the authority to decide whether to participate in PE. This issue brief, prepared by Manatt Health Solutions, describes the flexibility available to states to establish training and performance standards for hospitals conducting PE determinations, and discusses approaches states may want to consider as they develop standards.