Medicaid Expansions

The Affordable Care Act (ACA) dramatically expands Medicaid in 2014 in participating states. Meanwhile, six states have already expanded Medicaid since 2010 to some or all of the low-income adults targeted under health reform. The brief took an in-depth look at these six “early-expander” states — California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington — through interviews with high-ranking Medicaid officials.

The ACA gives qualified hospitals the opportunity to determine presumptive eligibility (PE) for all Medicaid-eligible populations which will enable hospitals to temporarily enroll individuals in Medicaid, ensuring compensation for hospital-based services, while providing patients access to medical care and a pathway to longer-term Medicaid coverage. This brief, prepared by the Center for Health Care Strategies, provides guidance to aid state Medicaid programs in developing the policies and procedures for hospital PE implementation. It provides valuable insight from the final CMS rule, related CMS guidance, expert sources, and interviews with states currently operating PE programs.

At the National Academy for State Health Policy’s Annual Conference in October 2013, Dr. Leininger presented on one potential method that Medicaid agencies can use to prepare for the the health needs of its new enrollment population under the ACA. This presentation reviews Dr. Leininger's findings on the feasability of embedding a health needs assessment into Medicaid applications to predict this population's future health needs.

One of the significant changes brought about by the Affordable Care Act (ACA) is the introduction of a new methodology to evaluate eligibility for Insurance Affordability Programs (IAPs): Modified Adjusted Gross Income (MAGI). MAGI will be used to evaluate available income for most Medicaid and Children’s Health Insurance Program (CHIP) applicants and enrollees beginning in 2014. MAGI will also be used to determine eligibility for Advance Premium Tax Credits (APTCs) and Cost Sharing Reductions (CSRs) through the health insurance Marketplaces.  This Advocate’s Guide explains how MAGI works, and sets forth the guidelines that CMS has developed to implement and govern this new methodology.

The findings in this report are drawn from the 13th annual budget survey of Medicaid officials in all 50 states and the District of Columbia. The report highlights trends in Medicaid spending, enrollment and policy initiatives for FY 2013 and FY 2014 with an intense focus on eligibility and enrollment changes tied to the implementation of the ACA as well as payment and delivery system changes.

In June 2012, Medicaid enrollment reached 54.1 million as high unemployment and falling incomes led many families to turn to Medicaid for coverage. However, as economic conditions improved, enrollment growth in Medicaid slowed. An additional 1.3 million people enrolled in Medicaid between June 2011 and June 2012 (a growth rate of 2.5 percent) compared to the program’s most recent peak at the height of the recessionary period, where nearly 3.5 million additional people enrolled each period (growth rates of 7.8 and 7.2 percent). The issue brief provides further analysis of enrollment trends across all 50 states and DC as well as within select eligibility groups such as families, the aged and disabled, as well as adult expansions of non-disabled, non-elderly adults.

A key method of stabilizing Medicaid coverage is to provide beneficiaries with twelve months of continuous eligibility. Following the passage of the Children’s Health Insurance Program Reauthorization Act in 2009, seven states adopted the continuous-eligibility option for children. That policy change led to a 1.8-percentage-point increase in the average length of child enrollment during fiscal year 2010 and increased annual costs for children by about 2.2 percent. The Medicaid and CHIP Payment and Access Commission has recommended offering states the option of giving adults twelve-month continuous eligibility for Medicaid. This study’s findings suggest that continuous eligibility could promote more stable coverage for adults enrolled in Medicaid at a modest cost.

Between 2010 and 2012, nearly one-third (32 percent) of U.S. adults ages 19 to 64, or an estimated 55 million people, were either continuously uninsured or spent a period of time uninsured. Data from the 2011 and 2012 Commonwealth Fund Health Insurance Tracking Surveys of U.S. Adults show that people with incomes below 133 percent of the federal poverty level (i.e., the level that will make them eligible for Medicaid in 2014 under the Affordable Care Act) were uninsured at the highest rates. Yet, fewer than half the states are currently planning to expand their Medicaid programs. In those states that have not yet decided to expand, as many as two of five (42 percent) adults who were uninsured for any time over the two years would not have access to the new coverage provisions in the law.

The final rule reducing Medicaid disproportionate share hospital (DSH) payments had few changes from the proposed rule. It cuts $500 million in fiscal 2014 and $600 million in fiscal 2015 allotments. The rule also defines the five factors that will be considered to generate a state-specific reduction allotment amount and establishes additional reporting requirements for the new DSH methodology.

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.