The ACA may greatly expand the number of people who are eligible for Medicaid. The law establishes a new eligibility group that states may choose to cover in their Medicaid program.
Who is eligible?
Low income adults who are not otherwise eligible under mandatory eligibility categories and have incomes below 133% of the Federal Poverty Level will now be eligible for Medicaid in states that choose to expand coverage. This means that eligible people must NOT be age 65 or older, pregnant, entitled to or enrolled in benefits under Medicare Part A or Part B, SSI beneficiaries, or other mandatory groups. People with disabilities who may not have a disability that currently qualifies them for Medicaid may be eligible.
What is 133% of the Federal Poverty Level?
For an individual, in 2013, it is about $15,282 per year. It varies by size of the family as shown below:
|133% of poverty
Will people receive traditional Medicaid services?
Newly eligible people in the expansion group will receive Alternative Benefit Plans (ABP). Similar to the process that states will use to select a benchmark plan for the health insurance marketplaces, states will pick from several different types of plans to be the benchmark plan. Once a state selects the benchmark plan, the state will check to make sure it covers the 10 categories of health care services known as the essential health benefits. HHS did not define the essential health benefit categories or provide guidance on what would be adequate coverage, so states will vary in how they cover these benefits.
For the Medicaid ABP states can establish more than one plan and target different plans to meet the needs of specific groups of people such as people with health conditions. States also have the flexibility to make the ABP the same as the traditional benefits available in Medicaid. States also have the flexibility to add home and community based services.
Are any categories of people exempt?
Some individuals who will be newly eligible in states that expand Medicaid will be exempt from mandatory enrollment in ABP. These individuals will have the choice of traditional Medicaid health care benefits or the ABP. Among the people who will be given this choice are people who are “medically frail.” This is a broad term the regulations use and it includes:
- individuals with serious and complex medical conditions, individuals with a physical, intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living;
- or individuals with a disability determination based on Social Security criteria;
- or individuals in states that apply more restrictive criteria than the Supplemental Security Income program, the State plan criteria and other groups.
For people with disabilities who meet the definition of “medically frail,” careful consideration of the different options (ABP or traditional Medicaid) will be necessary to decide what best meets the needs of the individual.
How will states determine who is medically frail?
Each state expanding Medicaid will need to tell HHS how they plan to identify people who are medically frail. HHS has not yet provided specific guidance on this issue. The streamlined application for Medicaid and the marketplaces ask whether the person or any family members have a disability. The question on the form is:
Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?
This question may help states identify people who should be screened for Medicaid eligibility though it is unclear if people with disabilities will respond yes to this question.
Can states privatize Medicaid through the expansion?
Over the years many states have experimented with privatizing Medicaid. Currently several states are considering new privatization arrangements as a way to implement Medicaid expansion. Specifically, some states are considering an approach called premium assistance, in which Medicaid funds are used to purchase private health insurance. HHS is expected to allow some states to experiment with this approach although they will need to provide consumer protections. To qualify, these plans must offer a set of benefits equivalent to the benchmark Medicaid expansion plan established in the state and must not cost beneficiaries any more in copays than they would pay under traditional Medicaid.
Does the Medicaid expansion help people seeking long term services and supports?
The expansion does not change current eligibility rules for home and community based services. People must meet current rules for determining financial eligibility including any asset test used in their state and the standards for having a disability and qualifying for services. However, as discussed above, states can choose to create very generous ABP for the people newly eligible as a result of the expansion.
When does the coverage expansion take effect?
There is not a deadline for states to expand coverage.
Who is paying for the expansion?
The federal government is paying 100% of the extra costs to cover the newly eligible individuals for the first three years. After 2016, the federal share is gradually reduced to 90% in 2020.
Updated August, 2013