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An Overview of State Approaches to Adopting the Medicaid Expansion

State approaches to adopting the Affordable Care Act’s Medicaid expansion have varied greatly by state based on state law, the political context, or other factors. While it does not cover how every state has enacted the Medicaid expansion, this issue brief highlights some of the different approaches states have taken to adopt the Medicaid expansion. Each state’s circumstances are unique, and the actions taken by one state may not apply to another state’s circumstances.

January State Data for Medicaid Work Requirements in Arkansas

Arkansas is one of seven states for which CMS has approved a Section 1115 waiver to condition Medicaid eligibility on meeting work and reporting requirements and the first state to implement this type of waiver. The new requirements were phased in for most enrollees ages 30-49 beginning in June 2018, and for individuals ages 19-29 starting in January 2019. Unless exempt, enrollees must engage in 80 hours of work or other qualifying activities each month and must report their work or exemption status by the 5th of the following month using an online portal; as of mid-December 2018, they also may report by phone. Monthly data related to the new requirements released by the Arkansas Department of Human Services show that over 18,000 people were disenrolled from Medicaid for failure to comply with the new requirements in 2018. Those who fail to comply with the requirements for any three months in 2019 can lose coverage beginning in April 2019. This brief looks at data for January 2019. Separate reports look at early implementation of the new requirements and enrollee experiences.

“Partial” Medicaid Expansions Could Limit States’ Spending But Cover Fewer People at a Higher Federal Cost Compared to Traditional ACA Expansions

If states were able to receive enhanced Affordable Care Act matching funds for “partial” expansions of Medicaid, fewer people would get health coverage and the federal government would spend more, compared to a traditional expansion under the law, KFF explains in a new brief. The explainer describes how a partial…

“Partial Medicaid Expansion” with ACA Enhanced Matching Funds: Implications for Financing and Coverage

The Affordable Care Act (ACA) provides enhanced federal matching funds to states that expand Medicaid to nonelderly adults up to 138% of the federal poverty level (FPL, $17,236/year for an individual in 2019). The ACA enhanced match (93% in 2019, and 90% in 2020 and thereafter) is substantially higher than states’ traditional Medicaid matching rate. A few states have sought Section 1115 demonstration waiver authority from the Centers for Medicare and Medicaid Services (CMS) to receive the substantially higher ACA enhanced match while limiting coverage to individuals at 100% FPL, instead of covering the full 138% FPL ACA group. To date, CMS has allowed states to receive the ACA enhanced Medicaid matching funds only if the entire expansion group is covered. CMS has not approved waiver requests seeking enhanced ACA matching funds for a partial coverage expansion in Arkansas or Massachusetts, while a request is pending in Utah. This brief explores the current rules for partial expansion and explains some of the potential implications for financing and coverage if CMS approves waivers to allow for partial expansion with enhanced matching funds.

Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers

Section 1115 Medicaid demonstration waivers provide states an avenue to test new approaches in Medicaid that differ from federal program rules. Waivers can provide states considerable flexibility in how they operate their programs, beyond what is available under current law. While there is great diversity in how states have used waivers over time, waivers generally reflect priorities identified by states and the Centers for Medicare and Medicaid Services (CMS). This brief answers basic questions about Section 1115 waiver authority and discusses the current landscape of approved and pending demonstration waivers.

Medicaid: What to Watch in 2019 from the Administration, Congress, and the States

Medicaid, the provider of health insurance coverage for about one in five Americans and the largest payer for long-term care services in the community and nursing homes, continues to be a key part of health policy debates at the federal and state level. Important Medicaid issues to watch in 2019 include Medicaid expansion developments amid ongoing litigation about the ACA’s constitutionality as well as Medicaid demonstration waiver activities, including those focused on work requirements and other eligibility restrictions. States are also likely to continue to pursue initiatives to address the opioid crisis, and the recent passage of bi-partisan legislation with new tools and financing could bolster these efforts. Primary areas of federal policy to watch in 2019 with implications for Medicaid include the expiration of temporary funding for Puerto Rico and the US Virgin Islands in the absence of legislative action as well as potential regulatory changes to public charge policies that would likely lead to Medicaid enrollment declines among immigrant families. Finally, reforms in benefits, payment and delivery systems continue to evolve as states and the federal government focus on managed care, social determinants of health, prescription drugs, and community based long-term care. While beyond the scope of this brief, Congress and states could also consider broader health reform that could expand the role of public programs in health care including Medicare for All or Medicaid buy-in programs that could have significant implications for Medicaid.

Medicaid Work Requirements in Arkansas: Experience and Perspectives of Enrollees

This brief presents perspectives of enrollees and safety net providers about Arkansas’ new Section 1115 Medicaid waiver work and reporting requirements based on focus groups and interviews. The discussions examine enrollees’ awareness of the new requirements and ability to set up online accounts for monthly reporting; the effect of the new requirements on enrollees’ work and common barriers to work; enrollees’ experience with monthly reporting; impacts on particular populations, such as those with disabilities or who are homeless; and the anticipated effects of coverage losses resulting from the new requirements.

New Rules for Section 1332 Waivers: Changes and Implications

On October 22, 2018, the Trump administration released new guidance on Section 1332 waivers established by the Affordable Care Act (ACA). The new guidance may encourage states to use 1332 waiver authority to make broader changes to insurance coverage for their residents, including to promote the sale of, and apply subsidies to, ACA non-compliant policies. On November 29, 2018, the Centers for Medicare and Medicaid Services (CMS) released a discussion paper outlining a set of waiver concepts designed to provide states with a roadmap for developing waiver applications that use the flexibility granted under the new guidance. This issue brief describes the new guidance, highlighting key changes from the 2015 guidance, describes how state waiver activity may change, particularly in light of the waiver concepts put forward by CMS, and discusses possible implications of the changes.