Medicaid expansion states where new governors withdrew pending work requirements:. Expansion states where work requirements have been approved by CMS but are not yet in effect as of late Lawmakers in Louisiana considered several work requirement bills in , but none were enacted.
Lawmakers in Pennsylvania passed Medicaid work requirement legislation in and again in , but Governor Tom Wolf vetoed both bills. Lawmakers in Alaska considered Medicaid work requirement legislation in , but the measure did not advance to a vote.
Several states that have not expanded Medicaid are seeking federal permission to impose Medicaid work requirements, despite the fact that their Medicaid populations are comprised almost entirely of those who are disabled, elderly, or pregnant, as well as children.
The Trump Administration has begun granting work requirements in some of these states, although CMS Administrator, Seema Verma clarified in May that these states would have to clearly demonstrate how they plan to avoid situations in which people lose access to Medicaid as a result of the work requirement, and yet also do not have access to premium subsidies in the exchange.
Two non-expansion states have been granted federal approval to implement Medicaid work requirements for their existing Medicaid populations:. Non-expansion states seeking federal permission to impose a Medicaid work requirement:. None are likely to be approved, given that the Biden administration has noted that work requirements are not in line with the overall mission of Medicaid ensuring access to health care. Kansas had also requested CMS approval for a work requirement of 20 or 30 hours per week, depending on circumstances.
And the bipartisan Medicaid expansion legislation that Kansas lawmakers considered in called for a work referral program instead of a work requirement. Lawmakers in Missouri also considered legislation that called for an 80 hour per month work requirement, but the bill did not pass in the session.
And voters in Missouri approved a ballot measure in that directs the state to expand Medicaid by mid But in November , the Trump administration published an interim final rule to update earlier rulemaking related to the COVID pandemic.
The new rules take effect immediately, but public comments were being accepted through January 4. The November guidance is called an interim final rule with request for comments, or IFC. In the IFC, the administration implemented a new approach, designed to give states more flexibility but also panned by critics as allowing states to reduce Medicaid benefits in the midst of a global health crisis. Under the IFC, states are still required to keep Medicaid beneficiaries enrolled in coverage unless they voluntarily disenroll or move out of state.
Most types of Medicaid coverage are considered minimum essential coverage, but there are a few exceptions. Under the IFC, a person whose Medicaid eligibility circumstances change eg, due to age, or length of time since a baby was born, etc. But if their original Medicaid coverage was considered minimum essential coverage, they could only be moved to a category that also provides minimum essential coverage.
And if their original category was not minimum essential coverage but did provide access to zero-cost COVID testing and treatment, they could only be moved to another category that also provides that benefit.
The IFC does not change anything about the first requirement for the enhanced federal Medicaid funding, which is that a state cannot make its Medicaid eligibility standards any more restrictive than they were at the start of So as noted above, Medicaid work requirements would still prevent a state from receiving the additional federal funding. Revising the IFC is among the various health care actions that the Biden administration could take, but they have not done so as of June But thus far, CMS has not approved this provision for any states.
The agency also rejected a similar proposal from Utah in , and from Georgia in Massachusetts has a similar request that is pending CMS approval , although Massachusetts has already expanded Medicaid. And no states have received approval for an asset test for Medicaid. Maine proposed an asset test as part of an waiver proposal, but that portion of the waiver was not approved.
Several states have received approval , however, to impose premiums on certain Medicaid populations, restrict retroactive eligibility, and require more eligibility redeterminations. Some other states followed suit to varying degrees over the coming years, but have since transitioned back to a more traditional approach Medicaid fee-for-service or Medicaid managed care. Arkansas is the only state that still uses the private option approach. New Hampshire enacted legislation in that directed the state to abandon the private approach to Medicaid expansion that was being used in the state at the time buying policies in the exchange for people eligible for expanded Medicaid and switch to a Medicaid managed care program instead.
The state submitted a waiver amendment proposal to CMS in August , and the transition took effect in This is an excellent overview of the status of Medicaid buy-in legislation in various states. Nevada lawmakers passed legislation to allow Medicaid buy-in during the legislative session, but the governor vetoed it.
Colorado lawmakers ultimately did not pass the bill , and neither did Maryland lawmakers. But New Mexico enacted legislation in early calling for a study on the costs and ramifications of a Medicaid buy-in program.
Lawmakers in New Mexico considered SB in which would have created a Medicaid buy-in program , but it did not pass. Thus far, Medicaid buy-in has not gained much traction. But Democrats have been warming to the idea of a public option or single-payer system. A public option program debuted in in Washington. Lawmakers in Colorado and Nevada are working on public option legislation during the session.
Expansions in Medicaid coverage of children marked the beginning of later reforms that recast Medicaid as an income-based health coverage program. Prior to the ACA, individuals had to be categorically eligible and meet income standards to qualify for Medicaid leaving most low-income adults without coverage options as income eligibility for parents was well below the federal poverty level in most states and federal law excluded adults without dependent children from the program no matter how poor.
The ACA changes effectively eliminated categorical eligibility and allowed adults without dependent children to be covered; however, as a result of a Supreme Court ruling, the ACA Medicaid expansion is effectively optional for states.
Under the ACA, all states were required to modernize and streamline Medicaid eligibility and enrollment processes. Expansions of Medicaid have resulted in historic reductions in the share of children without coverage and, in the states adopting the ACA Medicaid expansion, sharp declines in the share of adults without coverage. Many Medicaid adults are working, but few have access to employer coverage and prior to the ACA had no options for affordable coverage.
Figure 3: Medicaid has evolved over time to meet changing needs. In FY , Medicaid covered over 75 million low-income Americans. As of February , 37 states have adopted the Medicaid expansion.
Data as of FY when fewer states had adopted the expansion show that States can opt to provide Medicaid for children with significant disabilities in higher-income families to fill gaps in private health insurance and limit out-of-pocket financial burden. Medicaid also assists nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing and provides many of them with benefits not covered by Medicare, especially long-term care Figure 4.
Figure 4: Medicaid plays a key role for selected populations. Medicaid covers a broad range of services to address the diverse needs of the populations it serves Figure 5.
In addition to covering the services required by federal Medicaid law, many states elect to cover optional services such as prescription drugs, physical therapy, eyeglasses, and dental care.
Medicaid plays an important role in addressing the opioid epidemic and more broadly in connecting Medicaid beneficiaries to behavioral health services. EPSDT is especially important for children with disabilities because private insurance is often inadequate to meet their needs. Unlike commercial health insurance and Medicare, Medicaid also covers long-term care including both nursing home care and many home and community-based long-term services and supports.
More than half of all Medicaid spending for long-term care is now for services provided in the home or community that enable seniors and people with disabilities to live independently rather than in institutions. Some states have obtained waivers to charge higher premiums and cost sharing than allowed under federal rules. Many of these waivers target expansion adults but some also apply to other groups eligible through traditional eligibility pathways.
Over two-thirds of Medicaid beneficiaries are enrolled in private managed care plans that contract with states to provide comprehensive services, and others receive their care in the fee-for-service system Figure 6. Managed care plans are responsible for ensuring access to Medicaid services through their networks of providers and are at financial risk for their costs. In the past, states limited managed care to children and families, but they are increasingly expanding managed care to individuals with complex needs.
Close to half the states now cover long-term services and supports through risk-based managed care arrangements. Community health centers are a key source of primary care, and safety-net hospitals, including public hospitals and academic medical centers, provide a lot of emergency and inpatient hospital care for Medicaid enrollees.
Medicaid covers a continuum of long-term services and supports ranging from home and community-based services HCBS that allow persons to live independently in their own homes or in other community settings to institutional care provided in nursing facilities NFs and intermediate care facilities for individuals with intellectual disabilities ICF-IDs. This is a dramatic shift from two decades earlier when institutional settings accounted for 82 percent of national Medicaid LTSS expenditures.
Figure 6: Over two-thirds of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs. A large body of research shows that Medicaid beneficiaries have far better access to care than the uninsured and are less likely to postpone or go without needed care due to cost. Moreover, rates of access to care and satisfaction with care among Medicaid enrollees are comparable to rates for people with private insurance Figure 7. Medicaid coverage of low-income pregnant women and children has contributed to dramatic declines in infant and child mortality in the U.
These optional groups fall within the defined categories previously mentioned but the financial eligibility standards are more liberally defined. Optional eligibility groups include:. Poverty-related groups —States may choose to cover certain higher-income pregnant women and children defined in terms of family income and resources.
For example, some States have chosen to cover pregnant women and infants with family incomes up to percent of FPL or higher. Medically needy —States may choose to cover individuals who do not meet the financial standards for program benefits but fit into one of the categorical groups and have income and resources within special medically needy limits established by the State.
Individuals with incomes and resources above the medically needy standards may qualify by spending down—i. Recipients of State supplementary income payments —States have the option to provide Medicaid to individuals who are not receiving SSI but are receiving State-only supplementary cash payments.
LTC —States may cover persons residing in medical institutions or receiving certain LTC services in community settings if their incomes are less than percent of SSI.
Working disabled —States have the option to provide Medicaid to working individuals who are disabled, as defined by the Social Security Administration, who cannot qualify for Medicaid under any statutory provision due to their income. If States choose to cover this group, then they may also cover individuals who lose Medicaid eligibility as a result of losing SSI due to medical improvement.
States also have the discretion to expand eligibility beyond these optional groups. Through demonstrations, such as the research and demonstration project authority, and statutory provisions that allow less restrictive methodologies for calculating income and resources i.
This discretion has aided States significantly in their health care reform efforts. The Medicaid program is jointly financed by the States and the Federal Government. Medicaid is an entitlement program and the Federal spending levels are determined by the number of people participating in the program and services provided.
Federal funding for Medicaid comes from general revenues. The Federal Government contributes between 50 percent and 83 percent of the payments for services provided under each State Medicaid program. This Federal matching assistance percentage varies from State to State and year to year because it is based on the average per capita income in each State.
States with lower per capita incomes relative to the national average receive a higher Federal matching rate. The Federal matching rate for administrative costs is uniform for all States and is generally 50 percent, although certain administrative costs receive a larger Federal matching rate.
The Medicaid benefit package is defined by each State, based on broad Federal guidelines. There is much variation among State Medicaid programs regarding not only which services are covered, but also the amount of care provided within specific service categories i. Each State Medicaid program must cover mandatory services identified in statute. Some of the mandatory services include: inpatient and outpatient hospital services, physicians' services, rural health clinic and federally qualified health center FQHC services, laboratory and X-ray services, and well-child services i.
In addition to the mandated services, States have the discretion to cover additional services— i. States may choose among a total of 33 optional services to cover under their Medicaid programs, including prescription drugs, physical therapy, dental services, and eyeglasses.
Since Medicaid was enacted, the Federal Government has made significant changes in program eligibility criteria, financing, and services provided.
In addition, States have used their discretion to implement their own changes in the program. Many of the changes to the Medicaid program have been in response to the growing number of low-income individuals in need of medical assistance, the need to improve access to care, and the need to contain the rising costs of providing medical assistance.
The following are some of the legislative changes since the Medicaid program was established in One indicator of Medicaid growth and program evolution is the trend in enrollment.
In , Medicaid covered approximately 9 percent of the total U. By , Medicaid covered 12 percent of the total U. Many factors contribute to this increase in coverage; the most significant is the creation of new eligibility groups. The number of individuals served by the Medicaid program remained relatively constant from to The eligibility expansions mandated in the s led to significant increases among certain eligibility groups, especially pregnant women and children. Prior to implementation of these expansions, the number of persons served was approximately This number reached A recent decline in the number of individuals enrolled and served through Medicaid is attributed to a variety of factors including: fewer people in poverty, lower rates of unemployment, and the delinking of Medicaid and welfare assistance in i.
In particular, there has been a steady decline in the number of children enrolled in Medicaid since Figure 2. Projections of Medicaid enrollment for the next decade show moderate growth compared with the s. Total enrollment, measured in person years i. The blind and disabled population is projected to increase at twice the rate of all other eligibility groups.
Another enrollment trend is the increase in the number of non-cash beneficiaries. Non-cash beneficiaries qualify for Medicaid based solely on their income and resources e. The establishment of non-cash eligibility groups allows States to provide Medicaid to low-income individuals such as the working poor whose incomes preclude them from qualifying for cash assistance.
With the creation of non-cash eligibility groups, Medicaid has evolved to serve more than just welfare families. In fiscal year FY , less than one-half Not surprisingly, females comprise a larger share of the Medicaid population Medicaid provides protection for low-income women and their families from exhausting limited income and resources on LTC services.
Medicaid has also had an impact on women's health. Expansions in Medicaid eligibility coupled with presumptive eligibility for pregnant women and targeted outreach efforts e. The proportion of all women giving live births who started prenatal care during the first trimester increased from Infant mortality under 1 year of age has decreased from 9.
Medicaid plays a prominent role in providing health insurance to low-income children. Historically, children have represented the largest eligibility group served by Medicaid.
The eligibility expansions in the s, coupled with a recession, contributed to the significant growth in enrollment of children throughout the early s.
By the mid to late s, lower unemployment rates, due to a strong economy, contributed to a decline in Medicaid enrollment. Between and , the proportion of children covered by Medicaid dropped from As Medicaid enrollment has declined, the percent of uninsured children increased from Bureau of the Census, Figure 5. Medicaid coverage of children is significant among all age groups.
However, coverage is more prevalent among younger aged children. From to , Medicaid coverage of children under age 3 climbed from However, by the proportion of children under age 3 covered by Medicaid had dropped to 25 percent. Similar trends occurred in other age groups. In the age group , Less dramatic changes were seen for children in the age group In , Children including children with disabilities represent 54 percent of the The children Medicaid served in FY represented one out of five children in the Nation.
Over one-third of all children in the U. The number of Medicaid beneficiaries, age 65 or over, has grown only slightly over time. Growth in the number of elderly Medicaid beneficiaries has been much lower than the increase in the elderly U. In , Medicaid covered 3. In , Medicaid served nearly 4 million elderly beneficiaries, or 12 percent of the Bureau of the Census, The elderly's representation among all Medicaid beneficiaries has actually declined over time.
In , the population age 65 or over represented 19 percent of all Medicaid beneficiaries. In , individuals age 65 or over represented 11 percent of the Medicaid population U. Medicaid beneficiaries age 65 or over account for a disproportionate share of total Medicaid expenditures. This is due to the high cost of services utilized by this population e. In , elderly beneficiaries represented 11 percent of total Medicaid persons served yet they accounted for 31 percent of total Medicaid expenditures Figure 8.
The fastest growing Medicaid eligibility group is the disabled. Medicaid served approximately 6. The proportion of Medicaid beneficiaries with disabilities has increased over time. In FY , the blind and disabled represented 11 percent of the total Medicaid population receiving services with this growing to 18 percent by FY Figure 9. In terms of provider payments, growth in expenditures for the blind and people with disabilities outpaced other eligibility groups.
In , blind and disabled individuals served through Medicaid represented By , the blind and individuals with disabilities accounted for One contributing factor to the growth in this eligibility group and expenditures during this time period has been the acquired immunodeficiency syndrome AIDS.
Medicaid is the largest single payer of direct medical services for persons living with AIDS. The most significant trend in Medicaid services is the growth in LTC expenditures.
Medicaid is the primary source of LTC insurance for the elderly and people with disabilities, including middle-income individuals who spend down their financial resources. Medicaid covers skilled nursing facility care, intermediate care facilities for the mentally retarded and developmentally disabled, and home and community-based services. Medicaid's role as primary insurer for LTC has grown significantly.
In , Medicaid accounted for about 24 percent of total nursing home care expenditures. This accounts for almost one-half 46 percent of all U. The magnitude of Medicaid's nursing facility expenditures reflects the high cost of these services as well as the limited coverage under Medicare and private insurance.
Nursing facility expenditures also drive the distribution of Medicaid spending among beneficiaries. In , only 4 percent 1. Although most LTC is for institutional care, Medicaid has made great strides in shifting the delivery of services to home and community-based settings.
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