Trends in State Medicaid Programs: Looking Back and Looking Ahead

Laura Snyder and Robin Rudowitz
Published: Jun 21, 2016

Section 2: Eligibility and Application/Renewals

While required to cover core groups of enrollees, states have the flexibility to cover additional groups. The federal core minimum eligibility standards have expanded incrementally over time, mostly for children and pregnant women, as the Medicaid program separated from welfare. Moreover, many states have utilized the flexibility to extend eligibility to additional groups including children and individuals in need of nursing home care. Given this flexibility there is variation in eligibility levels across states. Federal policy changes have also had a significant effect on state activity in terms of eligibility standards and application and renewal processes – such as the Maintenance of Eligibility, options made available under CHIPRA as well as the ACA.

Over the course of the past decade, states have made a number of eligibility expansions. (Exhibit 2.1) Some states implemented broad coverage expansions prior to the data tracking in this survey like Arizona, Hawaii, Massachusetts, New York, Oregon and Vermont. A number of states implemented more limited coverage expansions during our survey tracking through demonstration waivers including Illinois, Iowa, Indiana, Oklahoma, Maine Maryland, Utah and Wisconsin. These coverage initiatives helped to address state priorities to reduce the uninsured and later became the foundation for coverage expansions under the ACA. In addition, some states implemented more targeted eligibility expansions such as reductions or eliminations of asset tests, adoption of options for the working disabled (such as TWIIAA), as well as expanding coverage those aging out of foster care. Other expansions stemmed from new options under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) and the ACA, such as those listed below.

Following CHIPRA, a number of states adopted federal options to expand coverage to pregnant women and children subject to the five-year bar.
ACA allowed seven states (Connecticut, District of Columbia, California, Colorado, Minnesota, New Jersey and Washington) to implement early expansions either through state plan amendments or through Section 1115 waivers ahead of the ACA Medicaid expansion in SFY 2014.
The number of states reporting eligibility standard expansions spiked in SFY 2014 as 26 states adopted the Medicaid expansion, increasing income eligibility for adults up to 138% FPL. New Hampshire, Pennsylvania and Indiana adopted the expansion in SFY 2015 and Alaska and Montana adopted in SFY 2016.¹ As of 2016, 32 states (including DC) have adopted the expansion. ² (Exhibit 2.2)

States have also implemented an array of simplifications to the application and renewal process. These efforts have included implementing or expanding the use of online applications, allowing individuals to self-declare their income, increasing the amount of time between redeterminations from 6 months to 12 months, removing face-to-face requirements and working with other agencies to share data. New options and requirements related to enrollment processes were included in CHIPRA and the ACA.

Enrollment options made available under CHIPRA included electronic data matching with the SSA to verify citizenship (instead of asking for paper documentation) and express lane eligibility (allowing states to enroll or renew children’s coverage by relying on information from other public programs like TANF or SNAP.)³
All states were required to streamline and simplify the enrollment process beginning in 2014. These changes include: a transition to the use of Modified Adjusted Gross Income (MAGI) to determine financial eligibility for children, pregnant women, parents and low-income adults; elimination of the asset limits for these same groups, and development of streamlined application, enrollment, and renewal processes coordinated across Medicaid and other health programs.⁴

Protections put in place during the recession and continued with the ACA prevented states from making restrictions eligibility and enrollment processes. (Exhibit 2.3) Prior to ARRA, eligibility and enrollment procedures have also been used by states as cost control measures. In the years leading up to the Great Recession, a few states made notable restrictions to eligibility standards, such as:

Tennessee restricted eligibility in its waiver in SFY 2006 resulting in the elimination of coverage for 171,000 adults following other eligibility reductions and freezes implemented in SFYs 2003 and 2005.
Missouri reduced eligibility standards across groups (adults, aged and disabled) in SFY 2006. Most notable restriction was reducing the income eligibility level for low-income parents from 75% FPL to AFDC income level (about 23% FPL) affecting 46,000 adults.
Florida eliminated full-benefit Medicaid coverage for 70,000 Medicare beneficiaries in the optional Medicaid for Aged or Disabled program in SFY 2006. A waiver program was created to cover individuals in the MEDS-AD program who were not eligible for Medicare.
Washington eliminated 12-month continuous eligibility affecting 350,000 children in SFY 2004. (Reinstated in SFY 2006)

Some states also reported changes to the application and renewal processes that made it more difficult for beneficiaries to enroll and renew coverage (e.g. instituting face-to-face requirements, increasing documentation requirements, requiring more frequent redeterminations, etc.)

However, Maintenance of Eligibility (MOE) provisions were established under ARRA that prohibited states from making cuts to eligibility standards or imposing more restrictive enrollment and renewal processes than those in effect July 1, 2008. The MOE provisions were extended under the ACA. States generally could not make restrictive changes to eligibility standards or enrollment procedures for adults until January 1, 2014 and MOE provisions are in effect for children through 2019. Therefore, only a few states (largely those with waiver renewals) reported eligibility or enrollment restrictions during this period.

Maintenance of Eligibility Requirements

As a condition of accepting additional federal fiscal relief through the ARRA, states were required to ensure that the eligibility standards, methodologies, or procedures under its Medicaid State Plan as well as under any waivers or demonstration programs were not more restrictive than those in effect on July 1, 2008. The ARRA enhanced funding and MOE requirements expired on June 30, 2011, but the ACA extended the ARRA MOE provisions. For adults, these provisions were extended through 2014 (when Marketplaces became operational) and for children through October 2019. Because of the link between eligibility for Medicaid LTC services and Medicaid eligibility generally, states were prevented from making some long-term care changes such as reducing occupied HCBS waiver capacity.⁵ Exceptions to the MOE requirements included: States were not required to renew waiver coverage that was expiring (Arizona in SFY 2011); and states could restrict eligibility for non-pregnant, non-disabled adults with incomes that exceed 133 percent of the federal poverty level if the state certified that they projected a budget shortfall (Hawaii, Illinois, Maine, Minnesota and Wisconsin in SFY 2013).