Web Briefing for Journalists: Key Issues Around Medicaid Expansion Efforts in the States Wednesday, February 18, 2015 Presented by the Kaiser Family Foundation

Rakesh Singh - Moderator Vice President for Communications Kaiser Family Foundation

Senior Policy Analyst Kaiser Family Foundation Laura Snyder – First Presenter

Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation Robin Rudowitz – Second Presenter

Medicaid is being transformed under the ACA. Delivery System Reforms Health Insurance Coverage for Certain Individuals Antiquated Enrollment Process Support for Health Care System Coverage for All Adults and Children Up to at Least 138% FPL at State Option Modernized, Simplified Enrollment Process BeforeACA Vision Shared Financing States and Federal Govt. Additional Federal Financing for New Coverage

NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius maintained the Medicaid expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL = $16,424 for an individual and $27,724 for a family of three in The ACA Medicaid expansion fills current gaps in coverage.

All states must modernize Medicaid application and enrollment processes. ACA VisionPAST Real-time determination Data Hub $ # Dear __, You are eligible for… Apply in person Multiple options to apply Provide paper documentation Electronic verification Wait for eligibility determination Medicaid CHIP Marketplace No Wrong Door to Coverage

NOTES: Under discussion indicates executive activity supporting adoption of the Medicaid expansion. *AR, IA, IN, MI, and PA have approved Section 1115 waivers. Coverage under the PA waiver went into effect on 1/1/15, but the newly-elected governor has stated he will transition coverage to a state plan amendment. Coverage under the IN waiver is set to begin 2/1/15. NH has submitted a waiver to continue their expansion via premium assistance. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts. Over half of states are currently implementing the Medicaid expansion. Adopted (29 States including DC) Adoption under discussion (7 States) Not Adopting At This Time (15 States)

NOTE: Data show the year over year change in spending between SFY 2014 and SFY Expansion states include 28 states; Indiana, which adopted the Medicaid expansion after this survey, is included in the non-expansion state group. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October Expansion states expect to see higher enrollment growth in FY 2015 with spending growth largely supported by federal funds.

The Medicaid expansion has implications beyond the Medicaid program. Increased State Economic Activity Increased Provider Revenue Reduction in the Number of Uninsured ↓ Uncompensated Care Costs ↓ State-funded health programs (e.g. Mental health) Increased State Savings Federal + State Funds + ↑ Jobs and Revenues

Source: Kaiser Commission on Medicaid and the Uninsured. The process for a state to adopt the Medicaid expansion requires partners at the state and federal level. State Law- makers State Medicaid Agency Federal Medicaid Agency (CMS) State Law or Regulation Medicaid State Plan Authorization and Appropriations State Plan Amendment (SPA) or Section 1115 Waiver In order to adopt the Medicaid Expansion, States must make changes to:

Approved WaiversProposed Waivers Waiver Provision ARIAINMIPA*NHUTTN Premium Assistance XXXXXX Premiums / Monthly Contributions XXXXXXX Healthy Behavior Incentives XXXXXX Benefits (NEMT) XXXXXX Work Referral X Reasonable Promptness X Retroactive Eligibility XXX Co-payments XXX Note: *Governor Wolf in PA said he will transition from a waiver to a SPA Most states are implementing the Medicaid expansion as set forth by law, but a limited number have approved or are seeking waivers. Newly approved provisions

Indiana waiver included approval for additional provisions: –6-month lock-out period for not paying premiums (between % FPL) –Coverage to begin after 60 days or after payment of premiums –Authority to implement higher co-payments ($8 for first visit and $25 for subsequent visits in the same year) for non-emergency ER use through § 1916(f) CMS has issued guidance to prohibit waivers to impose enrollment caps or implement partial expansion and access enhanced match CMS has denied proposals to: –Impose premiums as a condition of eligibility for beneficiaries below poverty –Waive certain required benefits such as EPSDT and free choice of family planning provider –Impose work requirements as a condition of eligibility What CMS approves or denies sets the guideposts for other states.

NOTE: Based on 2014 poverty thresholds. In states that have not expanded Medicaid under the ACA, there are large gaps in coverage available for adults. as of February % FPL $9,100 for parents in a family of three

Notes: Excludes legal immigrants who have been in the country for five years or less and immigrants who are undocumented. The poverty level for a family of three in 2015 is $20,090. Totals may not sum to 100% due to rounding. Source: “Number of Poor Uninsured Nonelderly Adults in the ACA Coverage Gap,” KFF State Health Facts. Nationwide, there are 3.7 Million low-income adults estimated to fall into the coverage gap. Total = 3.7 Million in the Coverage Gap Distribution By Geographic Region:Distribution By State:

Will more states adopt the Medicaid expansion? –Will more states submit waivers to implement the expansion? What will the effects of the Medicaid expansion be on the uninsured, state budgets overall, state economies and providers? What will we learn from current expansion waivers? –Effects on beneficiaries in terms of access to care and outcomes –Ability of states to administer and the federal government to track complex waiver programs How will Medicaid costs and coverage growth compare in expansion and non-expansion states going forward? How will individuals in the coverage gap fare? Looking Ahead

Q&A Discussion

Chris Lee, Senior Communications Officer Kaiser Family Foundation | Washington, D.C. Contact Information

NEW: An Overview of Actions Taken by State Lawmakers Regarding the Medicaid Expansion NEW: Are Uninsured Adults Who Could Gain Medicaid Coverage Working? UPDATED: The ACA and Medicaid Expansion Waivers Current Status of State Medicaid Expansion Decisions kff.org/medicaid Relevant Resources from KFF

Until next time, keep up with the Kaiser Family Foundation online: Facebook: /KaiserFamilyFoundation LinkedIn:/company/kaiser-family-foundation Alerts:kff.org/ Thank you!