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Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018

Eligibility and Premiums

Key Section Findings

Since 2014, most major eligibility changes have been related to adoption of the ACA Medicaid expansion. To date, 32 states have implemented the expansion (Louisiana was the latest state to adopt the expansion in FY 2017). Only a few states adopted other Medicaid eligibility expansions for FYs 2017 or 2018, and these changes were generally narrow in scope and targeted to a limited number of beneficiaries. The majority of states have policies in place to provide Medicaid coverage of inpatient care for those incarcerated in prisons or jails, to facilitate enrollment in Medicaid upon release, and to suspend, rather than terminate, Medicaid eligibility for incarcerated individuals.

What to watch:

  • For FY 2018, several states are seeking Medicaid eligibility restrictions through Section 1115 waivers that apply to ACA Medicaid expansion and/or traditional Medicaid populations, including the addition of work requirements, elimination of retroactive eligibility, and elimination of Medicaid expansion coverage for those with income above 100 percent of the federal poverty level (FPL).1 Several non-expansion states reported that consideration of the Medicaid expansion was on hold due to uncertainty about the future of the Medicaid expansion option.
  • Two states reported activity related to premiums in FY 2017 or FY 2018, both through Section 1115 waivers.

Tables 1, 2, and 3 at the end of this section include additional details on eligibility and premium policy changes in FYs 2017 and 2018.

Changes to Eligibility Standards

The ACA Medicaid expansion was one of the most significant Medicaid eligibility changes in the history of the program. By FY 2017, 32 states had implemented the ACA Medicaid expansion: 26 states in FY 2014; three states (Indiana, New Hampshire and Pennsylvania) in FY 2015; two states (Alaska and Montana) in FY 2016, and one state (Louisiana) on July 1, 2016 (FY 2017) (Figure 1).

Figure 1: Medicaid Expansion Decisions by Year of Implementation

Several non-expansion states (Idaho, Tennessee, Virginia, and Wyoming) reported that consideration of the Medicaid expansion was on hold due to uncertainty about the future of the Medicaid expansion option. North Carolina’s governor announced plans to adopt the expansion shortly after taking office in January 2017. These plans have been delayed, however, by a lawsuit brought by a group of legislators challenging the governor’s authority to expand without legislative approval.2 In Maine, voters will decide whether the state will adopt the ACA Medicaid expansion in a referendum this November.3

Other Eligibility Expansions

Beyond the ACA Medicaid expansion, states have made very few changes to expand Medicaid eligibility since 2014, and states reported only a few narrow expansions targeting a limited number of beneficiaries implemented in FY 2017 or planned for FY 2018 (Tables 1 and 2).

In addition to the ACA Medicaid expansion in Louisiana, a total of six other states made changes that expanded Medicaid eligibility in FY 2017. For FY 2018, seven states plan to implement eligibility expansions. Notable expansions reported include the following:

  • In FY 2017, both Florida and Utah implemented the option to eliminate the five-year bar on Medicaid eligibility for lawfully-residing immigrant children. Arkansas and Nevada both intend to implement this option in FY 2018 (pending CMS approval of their plans, which were adopted by both states’ legislatures during FY 2017).
  • In FY 2018, a pending Section 1115 waiver in Utah proposes covering a new eligibility group: individuals with income below 5 percent of the FPL who are chronically homeless, justice-involved, or individuals in need of substance use and/or mental health treatment.
Eligibility Restrictions

Only one state reported implementing an eligibility restriction in FY 2017: Missouri suspended its family planning waiver4 in FY 2017 following legislative restrictions contained in the state’s FY 2017 appropriations bill.5 Although Missouri replaced the Medicaid family planning waiver with a state-funded family planning program, this change eliminated Medicaid coverage for family planning services and placed new restrictions on which providers are accessible to the population. (The new restrictions apply only to individuals eligible through the waiver, however, and do not affect coverage of family planning services for other Medicaid eligible individuals.)

Eight states reported eligibility restrictions for FY 2018 (six states through Section 1115 waivers and two states through state plan authority), some in response to a March 2017 Trump administration letter to state governors6 that signaled an openness to approve Section 1115 waivers that include work requirements and more expansive use of premiums and cost sharing. This year’s survey captured changes that states have implemented or plan to implement in FY 2018, even if these changes are included in Section 1115 Waiver proposals that are pending approval 7 at CMS. Waiver provisions (in approved or pending waivers) that states plan to implement in FY 2019 or after are described later in the “Challenges and Priorities” section of this report.8 A description of key eligibility restrictions included in pending Section 1115 waivers planned for FY 2018 implementation follows.

FY 2018 restrictions for ACA Medicaid expansion populations:9

  • Arkansas 10 has proposed to amend its “Arkansas Works” Medicaid expansion waiver to: (1) eliminate coverage for persons with income above 100 percent of the FPL while still maintaining the enhanced federal matching rate for the remaining expansion population at or below 100 percent FPL, (2) include a work requirement for the remaining expansion population, and (3) eliminate the conditions CMS placed on the state’s waiver of retroactive eligibility for expansion enrollees (including the medically frail).11
  • Indiana 12 plans to impose a three-month lock-out from coverage on individuals who fail to comply with redetermination requirements. Beneficiaries who fail to verify eligibility at renewal would be disenrolled but could re-enroll without a new application if they provide necessary documentation within 90 days. After 90 days, a three-month lock-out period would follow before individuals could re-enroll.13

FY 2018 restrictions for non-ACA expansion Medicaid populations:

  • Iowa plans to eliminate retroactive Medicaid eligibility for all Medicaid enrollees with an October 1, 2017 target implementation date.14
  • Maine 15 plans to: (1) waive retroactive eligibility so that coverage would begin no earlier than the first day of the month of application, (2) impose a work requirement for adults (ages 19 to 64), such as parents and former foster care youth, and a time limit on coverage for those who fail to comply with work requirement, (3) apply a $5,000 asset test to all coverage groups that currently do not have an asset test, and (4) eliminate hospital presumptive eligibility for all coverage groups. The state’s pending waiver application proposes to implement these initiatives within six months of demonstration approval (the state’s estimated start date is January 1, 2018).16
  • Utah plans to impose a work requirement for its existing Primary Care Network (PCN) waiver adults,17 impose a 60-month time limit on eligibility for PCN adults, and end hospital presumptive eligibility for all current enrollees.
Utah’s Proposed Section 1115 Limited Medicaid Coverage Expansion
A pending Section 1115 waiver in Utah proposes covering a new eligibility group: individuals with income below 5 percent of the FPL who are chronically homeless, justice-involved, or individuals in need of substance use and/or mental health treatment. The state also plans to implement the following restrictive policies for this proposed new childless adults coverage group: 60-month time limit on coverage; no retroactive eligibility; and no hospital presumptive eligibility. Implementation is proposed for January 1, 2018.18
Premiums

The Medicaid statute generally does not allow states to charge premiums to Medicaid beneficiaries. Only two states reported activity related to Medicaid premiums in either FY 2017 or FY 2018.19 In FY 2017, Arkansas replaced the requirement that expansion enrollees make contributions to “Health Independence Accounts” with a new 2 percent of income premium requirement (up to $13/month) for expansion enrollees above 100 percent FPL. Indiana’s pending waiver includes requests to: (1) add a 1 percent premium surcharge for tobacco users beginning in the second year of enrollment, (2) require Transitional Medical Assistance parents with income up to 138 percent FPL to pay premiums like expansion adults, and (3) change to a tiered premium structure instead of a flat charge of 2 percent of income (this change is planned for FY 2018 and expected to have a neutral effect on beneficiaries) (Table 2). 

Coverage Initiatives for the Criminal Justice Population

In recent years, many states have implemented new policies to connect individuals involved with the criminal justice system to Medicaid given that the Medicaid expansion made many of these individuals newly eligible for coverage (including childless adults who were not previously eligible in most states). Connecting these individuals to health coverage20 can facilitate their integration back into the community. Individuals may be enrolled in Medicaid while they are incarcerated, but Medicaid cannot cover the cost of their care during their period of incarceration, except for inpatient services. Nearly all states have policies in place to cover inpatient care for individuals who are incarcerated under Medicaid. Most states are also working with corrections agencies and with local jails to facilitate enrolling individuals in Medicaid before they are released. In addition, half of the states (25) have enrollment initiatives to facilitate Medicaid enrollment for parolees. Some states train criminal justice employees to assist with Medicaid applications and other states have dedicated Medicaid staff to work with the corrections agencies to facilitate enrollment for inmates or payment for inpatient care of inmates. Finally, the majority of states suspend rather than terminate Medicaid coverage for enrollees who become incarcerated. When coverage is suspended, it can be reinstated more easily and quickly upon release from incarceration or when an inpatient hospital stay occurs.21

While both Medicaid expansion and non-expansion states have adopted these strategies to connect justice-involved individuals to Medicaid coverage, these initiatives affect many more people in expansion states because eligibility for adults remains restrictive in non-expansion states. In this year’s survey, one non-expansion state commented that the administrative costs of implementing Medicaid coverage policies for the criminal justice population would be excessive since the policies would apply to such a small number of people in the state.

Details on Medicaid coverage for individuals involved with the criminal justice system are included in Exhibit 1 and Table 3.

Exhibit 1: Coverage Initiatives for the Criminal Justice Population in FY 2017 and/or FY 2018 (# of States)
Select Medicaid Coverage Policies for the Criminal Justice Population Jails Prisons* Parolees
Medicaid coverage for inpatient care provided to incarcerated individuals 41 47 N/A
Medicaid outreach/assistance strategies to facilitate enrollment prior to release from incarceration or for parolees 33 40 25
Eligibility suspended (rather than terminated) for Medicaid enrollees who become incarcerated^ 36 37 N/A
^States that continue Medicaid eligibility for incarcerated individuals but limit covered benefits to inpatient hospitalization are also included in the count of states that suspend eligibility. *The District of Columbia has jails but not a prison system. However, DC is counted under Medicaid outreach/assistance strategies because some individuals who serve prison terms outside of DC may be placed in residential re-entry centers upon returning to DC and may apply for Medicaid to access coverage for 24-hour inpatient care and to facilitate enrollment prior to release.
Louisiana Medicaid and Corrections Policies
Louisiana has implemented several strategies to increase coverage and access to care for individuals released from incarceration, particularly those with high health care needs.Louisiana Medicaid shares data with the Louisiana Department of Corrections (LDOC), which adds incarceration and release dates to the Medicaid eligibility system. As a result of this data sharing, the state Medicaid agency can automatically identify individuals pre-release and begin planning nine months before the scheduled release date. Additionally, in FY 2017 the state began using a new system and streamlined application to enroll state prisoners in Medicaid prior to release and connect them to a health plan. As part of this process, the system also identifies high need individuals for discharge planning/case management. There are “high needs” markers for those with serious mental illness, substance use disorder, co-morbid medical conditions, or those who are “bed bound”. The Medicaid health plans are required to do pre-release care planning and ensure that there will be sufficient medications available at discharge for these high-need individuals.

Plans are underway to expand outreach/ enrollment assistance to local jails in FY 2018. 

Table 1: Changes to Eligibility Standards in all 50 States and DC, FY 2017 and FY 2018

Eligibility Standard Changes
States FY 2017 FY 2018
(+) (-) (#) (+) (-) (#)
Alabama
Alaska
Arizona
Arkansas X X X
California
Colorado X X
Connecticut
Delaware
DC
Florida X
Georgia
Hawaii
Idaho X
Illinois
Indiana X X
Iowa X
Kansas
Kentucky
Louisiana X-Medicaid Expansion
Maine X X
Maryland
Massachusetts X
Michigan
Minnesota X
Mississippi
Missouri X X
Montana
Nebraska
Nevada X
New Hampshire
New Jersey
New Mexico X
New York
North Carolina
North Dakota
Ohio X
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah X X X
Vermont
Virginia X X
Washington
West Virginia
Wisconsin
Wyoming X
Totals 7 1 1 7 8 2
NOTES: From the beneficiary’s perspective, positive changes counted in this report are denoted with (+), negative changes are denoted with (-), and neutral changes are denoted with (#). This table captures eligibility changes that states have implemented or plan to implement in FY 2017 or 2018, including changes that are part of pending Section 1115 waivers. For pending waivers, only provisions planned for implementation before the end of FY 2018 (according to waiver application documents) are counted in this table. Waiver provisions in pending waivers that states plan to implement in FY 2019 or after are not counted here.
SOURCE: Kaiser Family Foundation Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2017.

Table 2: States Reporting Eligibility22 and Premium23 Changes in FY 2017 and FY 201824

State Fiscal Year Eligibility Changes
Arkansas 2017 Premiums (New only for expansion population, under Sec. 1115 waiver): Arkansas Works program ended prior required contributions to “Health Independence Accounts” and replaced them with a 2% premium requirement for expansion populations with income 100-133% FPL (up to $13/month). Non-payment does not affect eligibility, but a debt to the state is accumulated (1/1/2017).
2018 Expansion Adults (-) Pending Sec. 1115 Waiver: Eliminate the conditions CMS placed on the state’s waiver of retroactive eligibility for expansion enrollees (including the medically frail), effective 1/1/2018 (60,000 individuals).25

Expansion Adults (-) Pending Sec. 1115 Waiver: Eliminate coverage for expansion population with income 100-133% FPL. (Implementation phased based on redetermination date.)

Expansion Adults (-) Pending Sec. 1115 Waiver: Work requirement for “remaining” expansion adults (0-100% FPL), similar to SNAP program.

Expansion Adults (#) Pending Sec. 1115 Waiver: End premium assistance program for employer sponsored insurance (40 individuals).

Children (+): Implement the CHIPRA option to eliminate the 5-year bar on Medicaid eligibility for legally-residing immigrant children.

Colorado 2017 Adults (+): Implementing annualized income for eligibility for MAGI populations (affects 3,000).
2018 Aged & Disabled (+) Planned Sec. 1115 Waiver: Medicaid buy-in option for individuals in support living services, spinal cord injury, & brain injury waivers.
Florida 2017 Children (+): Implement the CHIPRA option to eliminate the 5-year bar on Medicaid eligibility for legally-residing immigrant children.
Idaho 2018 Children (+): Cover children with severe emotional disorder in families with income between 185 and 300% FPL (1,000 children).
Indiana 2018 Expansion Adults (-) Pending Sec. 1115 Waiver: Three-month lock-out of coverage following a 90-day period of disenrollment for failure to comply with redetermination requirements.

Expansion Adults (#): End HIP Link premium assistance program for Employer Sponsored Insurance. (Enrollees will be moved to other HIP 2.0 coverage).

Premiums (New) Pending Sec. 1115 Waiver: Require Transitional Medical Assistance parents up to 138% FPL to pay premiums like expansion adults.

Premiums (New) Pending Sec. 1115 Waiver: Add a 1% premium surcharge for tobacco users beginning in the second year of enrollment.

Premiums (Neutral for Expansion Population) Pending Sec. 1115 Waiver: Seeking a tiered contribution amount instead of flat 2% of income, effective February 1, 2018 for the HIP 2.0 program.

Iowa 2018 All Groups (-) Pending Sec. 1115 Waiver: Eliminate retroactive eligibility, target effective date 10/1/17.
Louisiana 2017 Expansion Adults (+): Implemented Medicaid expansion on July 1, 2016 (430,000 individuals).
Maine 2017 Adults (+): Increased eligibility under family planning pathway to 209% FPL.
2018 Adults (-) Pending Sec. 1115 Waiver: Add a work requirement for many groups of adults ages 19-64: parents, former foster care youth, individuals receiving transitional medical assistance, medically needy parents/caretakers, individuals eligible for family planning services only, and individuals with HIV. Those who fail to comply with work requirement would be limited to no more than 3 months in a 36-month period.

All Groups (-) Pending Sec. 1115 Waiver: Eliminate retroactive eligibility.

Adults (-) Pending Sec. 1115 Waiver: Apply a $5,000 asset test to all coverage groups that do not currently have an asset test (under current law there is no asset test for coverage groups based solely on low income (vs. old age/disability)).

All Groups (-) Pending Sec. 1115 Waiver: Eliminate hospital presumptive eligibility.

Massachusetts 2018 Adults (-) Pending Sec. 1115 Waiver: Eliminate 90 day period of provisional eligibility for adults under age 65 without verified income who are not either pregnant or HIV positive (130,000).26
Minnesota 2017 Aged & Disabled (+): Increased income standard for the medically needy from 75% FPL to 80% FPL on 7/1/2016.

Adults (+): Added optional Medicaid eligibility group for family planning for those with income up to 278% FPL.

Missouri 2017 Adults (-): Family Planning Waiver ended and replaced with a state-only (non-Medicaid) program.
2018 Aged & Disabled (+): Asset limit doubled (10,005 individuals).
Nevada 2018 Children (+): Implement the CHIPRA option to eliminate the 5-year bar on Medicaid eligibility for legally-residing immigrant children.
New Mexico 2018 Aged & Disabled (-): Home equity exclusion changed from the federal maximum of $840,000 to the federal minimum of $560,000 (Fewer than 5 individuals).
Ohio 2017 Aged & Disabled (#): Conversion from 209(b) to 1634 for SSI related groups.
Utah 2017 Children (+): Implementing the CHIPRA option to eliminate the 5-year bar on Medicaid eligibility for legally-residing immigrant children (Estimated to affect 750 children).
2018 Parents & Caretakers (+): Increased the Basic Maintenance Standard to 55% FPL (3,000 individuals).

Adults (+) Pending Sec. 1115 Waiver: New eligibility group for chronically homeless, justice-involved individuals and those in need of substance abuse and/or mental health treatment, with income below 5% FPL.

Adults (-) Pending Sec. 1115 Waiver: Add a work requirement for Primary Care Network (PCN) group.

Adults (-) Pending Sec. 1115 Waiver: Eliminate of retroactive eligibility for PCN adults.

Adults (-) Pending Sec. 1115 Waiver: Add 60-month limit on eligibility for PCN adults.

Current Enrollees (-) Pending Sec. 1115 Waiver: Eliminate hospital presumptive eligibility.

Virginia 2017 Disabled (+) Under Sec. 1115 Waiver: Increased eligibility from 60% to 80% FPL for waiver services for people with serious mental illness (GAP waiver program). (Note: had been decreased from 100% FPL to 60% FPL in FY 2016.)
2018 Disabled (+) Under Sec. 1115 Waiver: Increase eligibility from 80% to 100% FPL for waiver services for people with serious mental illness (GAP waiver program) (2,000 adults with SMI). (Full restoration to pre-2016 level.)
Wyoming 2018 Adults (-): Income level for Breast and Cervical Cancer program reduced to 100% FPL (fewer than 50 individuals).

Aged & Disabled (-): Income level for Employed Persons with Disabilities program reduced to 100% FPL (163 individuals).

TABLE 3: CORRECTIONS-RELATED ENROLLMENT POLICIES IN ALL 50 STATES AND DC, FY 2017 AND FY 2018

States Medicaid Coverage For Inpatient Care Provided to Incarcerated Individuals Medicaid Outreach/Assistance Strategies to Facilitate Enrollment Prior to Release* Medicaid Eligibility Suspended Rather Than Terminated For Enrollees Who Become Incarcerated*
Jails Prisons Jails Prisons Jails Prisons
In place FY 2017 New or Expanded FY 2018 In place FY 2017 New or Expanded FY 2018 In place FY 2017 New or Expanded  FY 2018 In place FY 2017 New or Expanded FY 2018 In place FY 2017 New or Expanded FY 2018 In place FY 2017 New or Expanded FY 2018
Alabama  X*  X*  X*  X*  X*  X*
Alaska X X X X X X
Arizona X X X X X X X X
Arkansas X X X X X X
California X X X X X X
Colorado X X X X X X
Connecticut X X X X X X
Delaware X X X X  X*  X*
DC X N/A N/A X X X N/A N/A
Florida X X
Georgia X X
Hawaii X X X
Idaho X X
Illinois X X X X
Indiana X X X X X X
Iowa X X X X X
Kansas X X
Kentucky X X X X X X
Louisiana X X X X X X X
Maine X X X X
Maryland X X X X X X X X
Massachusetts X X X X X X
Michigan X X X X X X
Minnesota X X X X X X
Mississippi X X X
Missouri X X X X
Montana X X X X X X
Nebraska X X X
Nevada X X X X X X X
New Hampshire X X X X X X
New Jersey X X X X X X
New Mexico X X X X X X X X X
New York X X X X X X
North Carolina X X
North Dakota X X X
Ohio X X X X X
Oklahoma X
Oregon X X X X X X
Pennsylvania X X X X X X X X X X
Rhode Island X X X X X X
South Carolina X X X X X X
South Dakota X X X X
Tennessee X X X X
Texas X X X X
Utah X X X X
Vermont X X X X
Virginia X X X X X
Washington X X X X X X  X*  X*
West Virginia X X X X X X
Wisconsin X X X X
Wyoming
Totals 40 2 46 2 31 9 39 9 33 6 34 4

NOTES: ^States with “Medicaid outreach assistance strategies to facilitate enrollment prior to release” include those implementing a variety of strategies. In many cases, staff of the prison or jail provide most of the assistance in collaboration with the Medicaid agency. ^States that continue Medicaid eligibility for incarcerated individuals but limit covered benefits to inpatient hospitalization are also included in the count of states that suspend eligibility. “*” indicates that a policy was newly adopted in FY 2018, meaning that the state did not have any policy in that category/column in place in FY 2017.  N/A: The District of Columbia has jails but no prisons. However, DC is counted under Medicaid outreach/assistance strategies because some individuals who serve prison terms outside of DC may be placed in residential re-entry centers upon returning to DC and may apply for Medicaid to access coverage for 24-hour inpatient care and to facilitate enrollment prior to release.
SOURCE: Kaiser Family Foundation Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2017.

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