Medicaid Expansions

This final rule establishes the Basic Health Program (BHP), which provides states the flexibility to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace. The BHP complements and coordinates with enrollment in a QHP through the Exchange, as well as with enrollment in Medicaid and the Children’s Health Insurance Program (CHIP). This final rule also sets forth a framework for BHP eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, and federal oversight.

The expansion of Medicaid eligibility to Americans with incomes up to 138 percent of the federal poverty level should greatly increase access to coverage and services for people recently released from jail and, thus, improve health outcomes and reduce recidivism in this population. The population is disproportionately male, minority, and poor; suffers from high rates of mental and substance abuse disorders; and is expected to make up a substantial portion of the Medicaid expansion population. To ensure connections to needed services after release from jail, states could help inmates determine their eligibility and enroll in Medicaid; take advantage of federal grants to automate systems that determine eligibility; and include a robust array of behavioral health services in Medicaid benefit packages.

Many states have worked tirelessly over the past two years to develop health insurance exchanges and prepare for the expansion of their Medicaid programs in order to meet the requirements of the ACA. Programs to expand coverage, however, do not necessarily ensure seamlessness for many individuals who are likely to experience shifts in program eligibility due to changing circumstances (e.g., income fluctuations, family composition changes, etc.). A number of states are actively working to limit the impact of changes in program eligibility by developing policies that limit either the incidence of program eligibility changes and/or the impact those changes have on individual consumers. Various emerging state approaches take into account program history, the desire for state flexibility, and the political and operational challenges states face in developing coverage expansions that work for consumers, stakeholders, and policy makers.

Beginning in January 2014 all states must implement hospital PE and ensure that hospitals that participate in the Medicaid program can begin making PE determinations to provide temporary Medicaid coverage to individuals who qualify including children, pregnant women, parents, individuals formerly in foster care, and, if applicable in a state, adults covered under the new low-income adult eligibility group. CMS released this set of frequently asked questions for states and stakeholders regarding hospital PA. It discusses questions on the application process, the eligible populations, information on the qualified entities that can make hospital PE determinations, qualification standards for participating hospitals, and the federal matching funds available.

This fact sheet details state and hospital roles and responsibilities in implementing HPE programs. It outlines components necessary for HPE programs as well as requirements for state plan amendment submission.  It also includes a hypothetical example to illustrate how the HPE determination process can help an uninsured individual during a hospital visit.