How Will Medicare-for-all Proposals Affect Medicaid?

Eligibility and Enrollment

All U.S. residents, to be defined by the HHS Secretary.

Individuals to be auto-enrolled at birth.

All U.S. residents, to be defined by the HHS Secretary.

Individuals to be auto-enrolled at birth.

All US residents Individuals to be auto-enrolled at birth.

States must cover low-income parents, children, pregnant women, seniors, and people with disabilities. State options to expand coverage to all adults up to 138% FPL and to cover seniors and people with disabilities at higher income levels.

Legal immigrants generally ineligible for coverage for 5 years. Undocumented immigrants only eligible for emergency services.

Individuals must apply and periodically renew eligibility.

Covered Benefits

Medically necessary services, including hospital services, ambulatory patient services, primary and preventive services, mental health and substance abuse services, laboratory and diagnostic services, comprehensive reproductive services, pediatrics, rehabilitative and habilitative services, emergency services are covered.

States are required to continue covering any services covered through a Medicaid state plan amendment that are not included in the Medicare-for-all benefit package, and they may provide additional benefits at state expense

Medically necessary services, including hospital services, ambulatory patient services, primary and preventive services, mental health and substance abuse services, laboratory and diagnostic services, comprehensive reproductive services, pediatrics, rehabilitative and habilitative services, emergency services are covered.

States may provide additional benefits at state expense

Covers all medically necessary services, including emergency room visits, doctor visits, mental health and substance use disorder treatment, and comprehensive reproductive health services

All medically necessary services covered for children. Core set of services covered for adults, with additional services covered at state option.

Vision, dental, hearing

Covered

Covered

Covered

Covered for children; at state option for adults

EPSDT

Covered

Covered

Covered

Covered

Non-emergency transportation

Covered for people with low incomes and/or disabilities

Covered

Not addressed

Covered

Institutional long-term care

Medicaid coverage for these services would continue.

Covered, subject to functional eligibility criteria

Covered

Covered with state option to expand financial eligibility up to 300% SSI and impose asset limit, subject to functional eligibility criteria.

Community-based long-term care

Covered

Covered, subject to functional eligibility criteria

Covered

Covered primarily at state option for adults, with state option to expand financial eligibility up to 300% SSI and impose asset limit, subject to functional eligibility criteria.

Prescription drugs

Secretary to establish a formulary that discourages use of ineffective, dangerous or excessively costly drugs when better alternatives are available and promotes use of generic drugs. Off-formulary drugs are covered subject to rules established by Secretary.

Covered

Covered

All drugs with rebate agreement covered as medically necessary. State option to apply utilization controls such as prior authorization, preferred drug formulary

Premiums and Cost Sharing

None.

Limited authority for Secretary to require cost sharing for prescription drugs for those with income above 200% FPL.

None

No deductibles, and no co-payments for high quality care

State option to charge premiums to those above 150% FPL. Nominal cost-sharing, with certain services and populations exempt from all cost sharing. Cost sharing cannot exceed 5% household income.

Covered Providers

All state-licensed and certified providers who meet applicable provider standards and file a participation agreement.

All state-licensed and certified providers who meet applicable provider standards and file a participation agreement.

All Medicare providers, and possibly others eligible to participate

States establish provider licensing or other criteria. States must contract with federally qualified health centers.

Provider Payment

Secretary to establish a fee schedule in a manner consistent with the processes for determining Medicare payments and a new process for updating fees.

Payments established through global budget process and negotiations

Hospitals/facilities paid quarterly lump sum to cover operating expenses under a global budget; amount of payments determined by annual negotiation

Physicians/clinicians in general paid fee-for-service based on a fee schedule determined by the Secretary, taking into account current Medicare fee schedule, expertise of providers, information from national data/tracking program and subject to annual review

Doctors, nurses, and other providers will be paid appropriate rates

States set provider payment rates and methodology subject to general federal standards.

Delivery System

Fee-for-service; global budget for institutional providers; would allow current payment and delivery system reforms to continue

Fee-for-service; global budget for institutional providers

Private insurers permitted to offer managed care plans, but must meet strict consumer protections.

Will accelerate delivery system reforms and value-based care that rewards meaningful outcomes

Fee-for-service, managed fee-for-service, or managed care at state option.

State Role in Financing

State maintenance of effort (MOE) on spending on institutional long-term care as well as any Medicaid benefit provided through a state plan amendment that is not covered in the Medicare-for-all benefit package.

No state financing requirement

State financing MOE required, equal to current payment amounts indexed for inflation.

Jointly financed by state and federal dollars.