Status of State Medicaid Expansion Decisions: Interactive Map
Published: Feb 16, 2023
The Affordable Care Act’s (ACA) Medicaid expansion expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,120 for an individual in 2023) and provided states with an enhanced federal matching rate (FMAP) for their expansion populations.
To date, 40 states (including DC) have adopted the Medicaid expansion and 11 states have not adopted the expansion. Current status for each state is based on KFF tracking and analysis of state expansion activity.
These data are available in a table format. The map may be downloaded as a Powerpoint.
Key States with Expansion Activity
This table tracks state actions related to adoption of the ACA Medicaid expansion. For non-expansion states, we include actions toward potential adoption. These include legislative actions (passage of bills in at least one legislative chamber or committee), executive actions (Governor’s budget proposal, executive orders, or other significant announcements), and voter-led actions (progress toward ballot initiatives). We also mention some limited coverage expansions that would not qualify as full ACA Medicaid expansions and would not qualify for enhanced federal matching funds. For expansion states, we include summaries of when and how late-adopting states took up the expansion as well as notes on state attempts to place limits or requirements on the expansion population, especially through Section 1115 waivers.
|States||Summary of Activity|
|United States||Coverage under the Medicaid expansion became effective January 1, 2014 in all states that have adopted the Medicaid expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), Louisiana (7/1/2016), Virginia (1/1/2019), Maine (1/10/2019 with coverage retroactive to 7/2/2018), Idaho (1/1/2020), Utah (1/1/2020), Nebraska (10/1/2020), Oklahoma (7/1/2021), Missouri (Processing applications beginning 10/1/2021 with coverage retroactive to 7/1/2021), and South Dakota (Planned for 7/1/2023).
Arizona, Arkansas, Indiana, Iowa, Michigan, Montana, and Utah have approved Section 1115 waivers to operate their Medicaid expansion programs in ways not otherwise allowed under federal law. In some states, these included previously-approved Section 1115 work requirements that have since been withdrawn by CMS under the Biden Administration.
|STATES THAT HAVE ADOPTED AND IMPLEMENTED EXPANSION|
|Arkansas||In December 2021, CMS approved Arkansas’ Section 1115 waiver request which would replace the state’s current Medicaid expansion program, Arkansas Works, with the Arkansas Health and Opportunity for Me (ARHOME) program. CMS also notified Arkansas that it would phase out the state’s premium requirement for the expansion population by the end of 2022. Unlike Arkansas Works, ARHOME does not include work requirements. Under ARHOME, Arkansas is requesting to allow the state’s Qualified Health Plans (QHPs) to incentivize enrollee participation in health and economic independence initiatives and to consider QHP enrollees who do not participate in these incentives as “inactive” and reassign them to the state’s fee-for-service program; this aspect of the request is still pending CMS approval.|
|Idaho||Enrollment in Medicaid coverage under expansion began on November 1, 2019, and coverage for these enrollees began on January 1, 2020. Following a successful expansion ballot measure in November 2018, in 2019 Governor Brad Little signed a bill passed by the legislature that directed the Idaho Department of Health and Welfare to seek waivers for multiple changes to the expansion program and specified that if the waivers were not approved by January 1, 2020, then all individuals up to 138% FPL will be enrolled in Medicaid. The state submitted four waivers at direction from this legislation; however, only one has been approved to date.|
|Kentucky||On December 16, 2019, newly elected Democratic Governor Andy Beshear signed an executive order rescinding the Kentucky HEALTH waiver that had been set aside by the court in March 2019. The waiver had included a number of provisions including a work requirement, monthly premiums up to 4% of income, and coverage lockouts for failure to timely renew eligibility or timely report a change in circumstances. Kentucky’s expansion program was originally implemented and continues to operate under state plan amendment (SPA) authority.|
|Maine||Maine implemented expansion on January 10, 2019. Maine adopted the Medicaid expansion through a ballot initiative in November 2017. After former Governor LePage delayed implementation of the expansion for months, new Governor Mills signed an executive order on her first day in office (January 3, 2019) directing the Maine Department of Health and Human Services to begin expansion implementation and provide coverage to those eligible retroactive to July 2018. CMS approved the state’s plan retroactive to July 2, 2018 on April 3, 2019.|
|Missouri||In February 2022 the Missouri House passed a bill proposing a legislatively referred constitutional amendment that would impose work requirements on expansion enrollees and would also subject Medicaid expansion to legislative appropriations each fiscal year; however, the 2022 legislative session adjourned without the bill’s passage in the Senate. Missouri voters originally approved a ballot measure in August 2020 that added Medicaid expansion to the state’s constitution and prohibited any additional burdens or restrictions on eligibility for the expansion population. Medicaid coverage under expansion began when the state started accepting applications in August 2021 and began processing applications in October 2021, with coverage retroactive to July 1, 2021 consistent with a state supreme court order.
Previously, Governor Mike Parson announced that the state would not implement expansion because the ballot measure did not include a revenue source. In May 2021, individuals who would be eligible for expansion coverage filed a lawsuit against the state. However, in July 2021, the Missouri Supreme Court ruled that the initiated amendment is valid under the state constitution and that the legislature’s budget appropriation authorizes the state to fund expansion coverage.
|Montana||In December 2021, CMS notified Montana that it would phase out the state’s Section 1115 premium requirement for the expansion population by the end of 2022. Per May 2019 state legislation, Montana submitted a Section 1115 waiver amendment in August 2019 requesting to add a work requirement as a condition of eligibility and to increase the premiums required of many beneficiaries. CMS under the Biden Administration is unlikely to approve this pending request given the agency’s phase-out of Montana’s existing premium requirement and withdrawal of work requirement waiver provision in other states.|
|Nebraska||Enrollment in Medicaid coverage under expansion in Nebraska began on August 1, 2020, and coverage for these enrollees began on October 1, 2020. Nebraska voters had approved a Medicaid expansion ballot measure in November 2018, and the state delayed implementation to allow time to seek a Section 1115 waiver to implement expansion with program elements that differ from what is allowed under federal law, including a tiered benefit structure that requires beneficiaries to meet work and healthy behavior requirements to access certain benefits. While CMS approved this waiver on October 20, 2020, on August 17, 2021, the state requested to withdraw its approved waiver, which CMS subsequently approved on September 2. The state announced that it plans to offer all expansion adults full benefits starting October 1, 2021.|
|Oklahoma||Enrollment in Medicaid coverage under expansion in Oklahoma began on June 1, 2021, with coverage for these enrollees beginning on July 1, 2021. Oklahoma voters approved a ballot measure on June 30, 2020 which added Medicaid expansion to the state’s Constitution. Language in the approved measure prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.|
|South Dakota||Voters in South Dakota approved a ballot measure on November 8, 2022 which adds Medicaid expansion to the state constitution. Language in the approved measure specifies that South Dakota must implement expansion coverage beginning July 1, 2023 and prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.|
|Utah||Medicaid coverage under expansion began on January 1, 2020. Following a successful Medicaid expansion ballot measure in November 2018, the state legislature took steps to roll back the full expansion by directing the state to submit a series of Section 1115 waivers. On December 23, 2019, CMS approved certain provisions in the state’s “Fallback Plan” waiver request to amend its Primary Care Network Waiver to expand Medicaid eligibility to 138% FPL, effective January 1, 2020; the approval also included work requirements for the newly expanded adult Medicaid population. In February 2021, the Biden Administration began to withdraw waivers with work requirement provisions|
|Virginia||The Virginia General Assembly approved Medicaid expansion as part of its FY 2019-2020 budget on May 30, 2018; Governor Northam signed the budget into law on June 7, 2018. Expansion coverage became effective under state plan amendment (SPA) authority on January 1, 2019 after enrollment began on November 1, 2018.|
|STATES THAT HAVE NOT ADOPTED EXPANSION|
|Florida||An initiative to put Medicaid expansion on the 2020 ballot was delayed by its organizing committee.|
|Georgia||In December 2021, CMS under the Biden Administration withdrew Georgia’s Section 1115 approval for work and premium requirements in the state’s Pathways to Coverage waiver. However, in August 2022, a Federal District Court judge issued a decision vacating CMS’s rescission of Georgia’s waiver provisions, thus reinstating these provisions (though CMS may appeal the decision). Following this decision, Republican Governor Brian Kemp allocated $52 million in his proposed state fiscal year (FY) 2024 budget to implement the waiver program beginning July 1, 2023. The waiver, which would not be a full Medicaid expansion under the ACA and would not qualify for enhanced matching funds, was initially approved in October 2020 and gives Georgia authority to extend Medicaid coverage to 100% FPL for parents and childless adults. Initial and continued enrollment would be conditioned on compliance with the work and premium requirements.|
|Kansas||In January 2023 following her re-election, Democratic Governor Laura Kelly included Medicaid expansion in her proposed budget for State Fiscal Year (SFY) 2023. The proposal directs the state to expand Medicaid by January 2024 and accounts for additional federal Medicaid matching funds due to the American Rescue Plan Act (ARPA) incentive for states to newly adopt expansion. Kelly has included expansion in previous budget proposals and proposed legislation since the start of her term in 2019, though none have been passed by the Republican-controlled legislature.|
|Mississippi||Although Mississippi’s Secretary of State approved a 2022 Medicaid expansion ballot initiative for circulation in April 2021, on May 19 the organizing committee suspended its campaign following a Mississippi Supreme Court decision ruling that the state’s entire ballot initiative process is inoperable due to procedural errors regarding ballot initiative language in the state’s constitution. While Medicaid expansion was a key issue in the 2019 Mississippi gubernatorial election, current Republican Governor Tate Reeves opposes expansion, making it unlikely that the state will take up expansion through legislation.|
|North Carolina||On February 16, 2023, North Carolina’s House passed legislation that would direct the state to expand Medicaid by January 2024. The legislation additionally includes provisions to increase hospital assessments to fund the state share of expansion, increase hospital reimbursement rates, and implement a comprehensive workforce development and referral program, and seek federal approval to condition Medicaid eligibility on compliance with work requirements if there is any indication that work requirements as a condition of participation in Medicaid may be authorized by CMS.
In 2022, both the House and Senate passed bills related to Medicaid expansion, but neither bill advanced due to disagreements between the two chambers on unrelated provisions. In June 2022, the North Carolina Senate passed a bill that would direct the state to expand Medicaid by July 2023 and seek federal approval to impose work requirements on beneficiaries as a condition of eligibility on expansion enrollees. The Senate bill additionally included certificate of need provisions. The House separately passed a bill the same month that would task a joint legislative study committee with voting on a recommended Medicaid expansion plan in December 2022 and direct the state to create a Medicaid work referral program and seek federal approval to condition Medicaid eligibility on compliance with work requirements. In previous years, Democratic Governor Roy Cooper proposed Medicaid expansion in his state budget proposals, but the legislature omitted expansion in its final budget.
|South Carolina||On December 12, 2019, CMS approved two separate 1115 waivers for South Carolina which would extend Medicaid coverage from 67% to 100% FPL for its parent/caretaker relative groups and a new targeted adult group with initial and continued enrollment conditioned on compliance with work requirements at the regular match rate; this coverage would not qualify as a full Medicaid expansion under the ACA. In February 2021, the Biden Administration began to withdraw waivers with work requirement provisions.|
|Wisconsin||After the Wisconsin Legislature’s Joint Finance Committee voted to remove Medicaid expansion funding from Democratic Governor Tony Evers’ State Fiscal Years (SFY) 2022-2023 budget proposal, Governor Evers signed an executive order to hold a special session for Medicaid expansion legislation on May 25, 2021, proposing to use the additional federal funds the state could receive under the incentive in the American Rescue Plan Act for other state development projects. However, on May 25, the Republican-controlled legislature adjourned the special session without further action, and the legislature passed a SFY 2022-2023 budget without Medicaid expansion funding on June 30. The governor had included Medicaid expansion in his previous budget proposal for FY 2020-2021, but the Republican-controlled legislature did not include it in the final budget. Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the ACA expansion.|
|Wyoming||A Medicaid expansion bill that passed the Wyoming House for the first time subsequently failed a vote in the Senate Labor, Health, and Social Service Committee in March 2021. However, on October 22, 2021, the legislature’s Joint Revenue Committee reintroduced this legislation ahead of an October special session—the legislation did not advance. The bill would expand Medicaid contingent on the state continuing to receive a 90% federal match assistance percentage (FMAP) for the expansion population and at least 55% for the traditional Medicaid population (a 5 percentage point increase from the traditional match rate of 50%, which is an incentive included in the American Rescue Plan Act for adopting expansion). Prior to the new ARPA incentive, the Wyoming legislature had rejected multiple Medicaid expansion bills during the 2020 and other previous legislative sessions.|
Medicaid Expansion Resources
- New Incentive for States to Adopt the ACA Medicaid Expansion: Implications for State Spending
- Building on the Evidence Base: Studies on the Effects of Medicaid Expansion, February 2020 to March 2021
- The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020
- Effects of the ACA Medicaid Expansion on Racial Disparities in Health and Health Care
- The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid
- Medicaid Expansion Enrollment and Spending Leading up to the COVID-19 Pandemic
- Medicaid: What to Watch in 2021
- Eliminating the ACA: What Could It Mean for Medicaid Expansion?
- Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State
- The Uninsured and the ACA: A Primer – Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act
- Medicaid State Fact Sheets
- An Overview of State Approaches to Adopting the Medicaid Expansion