Medicaid Expansions

The ACA required Medicaid to cover all children with incomes up to 138 percent of the federal poverty level (FPL) as of January 2014. Whereas all states were previously required to cover children under age 6 in families with incomes up to 138 percent of FPL and children ages 6 to 18 up to 100 percent of FPL through Medicaid, children ages 6 to 18 with family incomes between 100 and 138 percent of FPL were permitted to be covered through separate CHIP. At the time the ACA was enacted, 21 states covered these so-called “stairstep” children through separate CHIP and thus needed to transition them to Medicaid in order to comply with the ACA requirement. Such a transition raises concerns about continuity of coverage and access for children transitioning, along with concerns about potential confusion for parents and providers. This report describes 10 states’ approaches to the transition, identifying common challenges and lessons learned that could support future transitions between health coverage programs.
 

This letter to state health officials and Medicaid directors clarifies and expands upon the opportunities for facilitating Medicaid and the Children’s Health Insurance Program (CHIP) enrollment. In particular, it is offering states a new opportunity under Medicaid state plan authority to use Supplemental Nutrition Assistance Program (SNAP) gross income to support Medicaid income eligibility determinations at both initial application and renewals for certain populations.

Similar to other reports recently released, new data examining hospital discharges in 16 states show increases in Medicaid discharges and declines in uninsured or self-pay discharges in states that implemented the Medicaid expansion. These trends hold true for all hospital discharges as well as for specific services such as mental health or asthma. This information adds to a growing body of evidence demonstrating how coverage expansions are affecting providers and may lead to decreases in uncompensated care for the uninsured.

Through the Medicaid Accountable Care Organization Learning Collaborative, the Center for Health Care Strategies has developed a library of practical resources for states considering and implementing accountable care organizations (ACOs) for Medicaid populations. These resources are designed to help states and provider organizations develop and launch Medicaid ACOs.

Since the June 2012 Supreme Court decision effectively made Medicaid expansion under the ACA optional for states, the effects of the Medicaid expansion on state budgets and economies have been key issues for policymakers. This brief provides some insight into the underlying economic and fiscal conditions in expansion and non-expansion states leading up to 2014. The brief will provide a framework against which to measure the impact of expansion decisions going forward.

Born as an afterthought to Medicare five decades ago, Medicaid has evolved from an adjunct to state welfare programs to the nation’s largest health insurer. The occasion of Medicaid’s 50th birthday is a fitting time to consider that evolution, not to reminisce, but to help chart the path forward. Medicaid is a complex program with a complex history, and understanding its role in the U.S. health system is essential to ensuring that it is performing at optimal levels for its beneficiaries, as well as for states, taxpayers, and the myriad health care providers, health plans, and others touched by the program. In this four-part series, Cindy Mann and Deborah Bachrach of Manatt Health Solutions examine Medicaid’s evolution and consider its role in the new coverage paradigm established by the ACA.

As millions of Americans gain Medicaid coverage under the ACA, attention has focused on the access to care, quality of care, and financial protection that coverage provides. This analysis explores these questions by comparing the experiences of working-age adults with private insurance, Medicaid beneficiaries, and those who are uninsured. The survey findings suggest that Medicaid coverage provides access to care that in most aspects is comparable to private insurance. Adults with Medicaid coverage reported better care experiences on most measures than those who had been uninsured during the year. Medicaid beneficiaries also seem better protected from the cost of illness than are uninsured adults, as well as those with private coverage.

A health insurance marketplace renewal process that accounts for both enrollee convenience and the changing value of financial assistance from year to year will likely play an important role in maintaining overall enrollment and long-term sustainability for state-based marketplaces. Through marketplace enrollment data and interviews with marketplace officials, insurer representatives and navigators, this paper examines how six state-based marketplaces experienced the first year of renewals. It finds that while the marketplaces approached renewals differently, they faced similar challenges, but were successful overall in retaining a substantial proportion of their 2014 enrollees.

Because eligibility for Medicaid is determined by current monthly income, many beneficiaries temporarily lose coverage when their seasonal employment or overtime pay increases, and later requalify when their income dips. This churning can result in disruptions in care for the beneficiaries, and places administrative burdens on states and Medicaid managed care plans. This study reviews four policy options for addressing the problem and simulated their impact on churning and enrollment. The options include: 1) extending coverage to the end of the calendar year; 2) granting coverage for 12 continuous months, regardless of changes in income or life circumstances; 3) basing eligibility on an estimate of annual income; and 4) extending coverage by three months when a change in income or life circumstances causes a loss of eligibility.

Eighteen states are currently participating in the Medicaid Balancing Incentive Program (BIP) to increase access to home and community-based services (HCBS) as an alternative to institutional care. Established by the ACA, BIP authorizes $3 billion in enhanced federal funding from October 2011 through September 2015. During the summer of 2014, the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured surveyed BIP states about basic program information, progress with implementing the BIP structural requirements, stakeholder engagement, evaluation activities, and the use of enhanced federal funds in support of other Medicaid LTSS rebalancing efforts. This report documents the key findings.