Background

The Medicaid program, which was enacted in 1965, is the primary source of insurance coverage for certain low-income individuals, including children, pregnant women, individuals with disabilities, and parents of minor children. Medicaid also provides coverage to low-income Medicare beneficiaries for services not covered by Medicare, such as cost-sharing and long-term care. Some populations are mandatory populations that the states are required to cover, while others are optional.

Despite the perception that Medicaid covers all poor people, the program has never recognized all low-income adults as a coverage group in its own right. Moreover, Medicaid’s financial eligibility standards for parents can vary widely, causing extreme disparities in eligibility from state to state. In one state, Medicaid eligibility for a parent is less than 17 percent of the federal poverty level (FPL),   and in ten states eligibility levels are under 33 percent. In those ten states a single parent with one child who earns $5,000 per year earns too much to qualify for Medicaid. Conversely, some states provide coverage to parents at up to or exceeding 185 percent of the FPL, which covers a single parent with one child with nearly $27,000 in annual income.^[1] For adults without minor children, most states provide no coverage, while a handful provide Medicaid or provide coverage without federal assistance.

In deciding who qualifies for Medicaid, states also have tremendous flexibility in determining what income, assets, and resources count as income. One state may, for example, decide not to count certain types of income so that more people qualify for Medicaid coverage, while others states seeking to limit those who can qualify will count assets, such as a car. This flexibility contributes further to the variation in eligibility from state to state.

Changes Made by the Health Reform Law
P.L. 111- 148, §§ 2001, 2002, 2004, 2202, and P.L. 111-152, § 10201

Generally, the health reform law expands Medicaid to provide a uniform level of coverage to all U.S. citizens and legal immigrants with incomes below 133 percent of the FPL by 2014. In the interim, the law permits states to phase in coverage, to improve certain benefits, and to begin moving toward uniform income and eligibility standard. Without some uniformity in who qualifies for Medicaid, it will be difficult to assure that low-income families have access to either the Medicaid program or to the tax credits to purchase coverage. According to the Congressional Budget Office (CBO), an estimated 16 million additional individuals will receive coverage through Medicaid and the Children’s Health Insurance Program (CHIP) when fully implemented.^[2]

Effective Date of Enactment

• Includes maintenance of effort provisions requiring states to maintain Medicaid coverage of adults at their current income and resource levels through December 31, 2013, and for children enrolled in Medicaid and CHIP through September 30, 2019. Provides an exemption for coverage of adults for states experiencing budget deficits.
• Establishes a new category of eligibility for family planning services and supplies for individuals who are not otherwise Medicaid-eligible with incomes below the highest level covered for pregnant women under Medicaid and CHIP.
• Applies spousal impoverishment protections to home and community-based services, allowing the Medicaid beneficiary’s spouse to retain sufficient resources to continue living at home.

April 1, 2010

• Permits states to expand Medicaid eligibility to individuals not otherwise eligible for Medicaid with incomes below 133 percent of the federal poverty level (FPL).^[3] States are permitted to phase in coverage of expansion population with states and the federal government paying their current shares of the cost.

Effective October 1, 2011

• Allows states to expand home and community-based care to individuals with incomes below 300 percent of Supplemental Security Income Limit eligibility levels.

Effective January 1, 2014

• Requires states expand Medicaid to cover “newly eligible”  individuals with incomes under 133 percent of the (FPL). These individuals are primarily childless adults and parents who were not eligible for Medicaid coverage on December 1, 2009. Newly eligible individuals will be eligible for a narrower range of benefits, known as “benchmark coverage.”  States have the option of phasing in coverage for these populations beginning April 1, 2010.
• Allows states to cover parents and childless adults with incomes over 133 percent of FPL.
• Expands Medicaid to cover children under age 26 who were enrolled in foster care. Before enactment of the health reform law, these children lost eligibility for Medicaid once they aged out of foster care, unless states chose to cover them through age 21 under a state option.
• Establishes uniform eligibility requirements under Medicaid by directing states to use “modified adjusted gross income”  standards to determine Medicaid eligibility. States may implement earlier, subject to maintenance of effort provisions.
• Permits states to expand Medicaid “presumptive eligibility”  to newly eligible individuals if they have adopted presumptive eligibility for other Medicaid eligible populations including children, pregnant women, and women with breast or cervical cancer.
• Adds hospitals that participate in Medicaid to the list of qualified providers permitted to make presumptive eligibility determinations.

Implementation

Agency and Timeline

The Centers for Medicare and Medicaid Services (CMS), Center for Medicaid and State Operationswithin the Department of Health and Human Services will implement this program as part of its authority over the Medicaid program. The Secretary is directed to submit an annual report to Congress beginning in April of 2015 on total enrollment and new enrollment in Medicaid.

Process

The health reform law does not provide specific direction to the Secretary regarding the administrative process used to implement the law. The agency therefore has the discretion to use a range of tools to implement the statute, such as publishing regulations in the Federal Register with a public notice and comment period or using other types of approaches such as posted policy instructions, announcements of funding availability announcements (where applicable), official letters to affected entities (such as letters to state Medicaid agencies) and posted rulings and notices. Agency websites can be regularly checked for updates.

Key Implementation Issues

Often CMS provides general guidance to states through letters to state Medicaid directors. States make changes to their programs through state plan amendments. States also make program changes through waivers. Implementation issues will likely arise in the discussions between CMS and the states.

• Maintenance of effort:
  • How strictly will CMS interpret existing coverage standards when defining maintenance of effort?
  • What criteria will the Secretary use to approve of waivers maintenance of effort provisions for states operating at a deficit?
• Relationship with Exchanges:
  • What guidance will CMS provide to states to facilitate identification and enrollment of Medicaid-eligible individuals who apply for private coverage through the exchange?
  • How will the federal exchange, which will cover people in states that fail to operate their own, interact with state-based Medicaid eligibility and enrollment systems?
• Eligibility determinations:
  • What guidance, requirements or technical assistance will CMS provide to state Medicaid agencies to help them transition from their current eligibility processes to new ones based on modified adjusted gross income?
• Approvals:
  • What steps will CMS take to assure timely review and approval of state plan amendments and waivers?
  • How will CMS treat existing waivers that are subject to renewal before January 1, 2014?

Recent Agency Action

On April 9, 2010, the Director for the Center for Medicaid and State Operations within CMS issued a letter to State Medicaid Directors providing guidance on § 2001 announcing the availability of state matching funds for low-income adults.

Authorized Funding Level

As an entitlement program, Medicaid is not limited to a specified appropriation level under federal law. Each year, Congress appropriates, “such sums as may be necessary” for the federal government to meet its federal matching obligations to states. According to CBO, coverage expansions in Medicaid and CHIP will result in an increase of $20 billion over 10 years, most of this cost will be in the form of additional funding to states to cover the cost of the newly eligible individuals. (See entry on Medicaid: FMAP for more information). CBO did not provide separate estimates for Medicaid and CHIP.