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 set of FAQs provides additional clarification on strategies for administering telephonic Medicaid and CHIP applications, how states should handle eligibility renewals in 2014, and who will receive the 75 percent match in eligibility systems. It also provides guidance on MAGI-based eligibility and transitioning children between 100-133 percent of the FPL from CHIP to Medicaid.

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.  

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.

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. 

This rule finalized a slew of regulations related to the structure and operations of Medicaid, CHIP, and exchanges under the ACA. These include eligibility and enrollment requirements for qualified health plans and insurance affordability programs (Medicaid, CHIP, APTCs, and Basic Health Plans). It also detailed minimum standard requirements for Alternative Benefit Plans and changes to eligibility notices and appeals for Medicaid and CHIP. Additionally, it updated the criteria for verification of eligibility and enrollment in employer-sponsored insurance.

One of the major vehicles in the ACA to increase health insurance coverage is an expansion of Medicaid to adults with incomes at or below 138% of the federal poverty level (FPL). While the expansion was intended to be implemented in all states, as a result of the Supreme Court decision on the ACA, it is now effectively a state choice. As of July 1, 2013, 24 states are moving forward with the expansion, 21 states are not planning to move forward, and there is ongoing debate in 6 states. Based on an analysis of 2011 American Community Survey data, this brief examines the implications of current state Medicaid expansion decisions on coverage by race and ethnicity.

In this report, MACPAC examines several fundamental issues including Medicaid and CHIP eligibility and coverage for maternity services, the newly implemented increase in physician payment for primary care services, access to care for non-elderly persons with disabilities, the availability of Medicaid and CHIP data that can be used for oversight and program monitoring, and improving the effectiveness of program integrity activities.

This rule finalizes new Medicaid eligibility provisions; finalizes changes related to electronic Medicaid and the Children’s Health Insurance Program (CHIP) eligibility notices and delegation of appeals; modernizes and streamlines existing Medicaid eligibility rules; revises CHIP rules relating to the substitution of coverage to improve the coordination of CHIP coverage with other coverage; and finalizes requirements “alternative benefit plans” to ensure that these benefit packages include essential health benefits and meet certain other minimum standards. This rule also implements specific provisions including those related to authorized representatives, notices, and verification of eligibility for qualifying coverage in an eligible employer-sponsored for exchanges. A fact sheet is available.

The ACA will have important impacts on state Medicaid programs, likely increasing participation among populations that are currently eligible but not enrolled. The size of this “welcome-mat” effect is of concern for two reasons. First, the eligible but uninsured constitute a substantial share of the uninsured population in some states. Second, the newly eligible population will affect states’ Medicaid caseloads and budgets.